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COPYRIGHT DEPOSrT. 



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A MANUAL 



CLINICAL DIAGNOSIS 

BY MEANS OF MICROSCOPICAL AND 
CHEMICAL METHODS, 



FOR 



STUDENTS, HOSPITAL PHYSICIANS, AND PRACTITIONERS. 



BY 



CHARLES E. SIMON, M.D. ; 



Of Baltimore, Md. 



FOURTH EDITION, THOROUGHLY REVISED. 



ILLUSTRATED WITH 139 ENGRAVINGS AND 19 PLATES IN COLORS. 




LEA BROTHERS & CO., 
PHILADELPHIA AND NEW YOKK, 

1902. 




551 



THE LIBRARY OF 

CONGRESS, 
Two Cu«E8 Reobved 

JAN. 17 1902 

-CWVWGHT ENTRY 

cLass ^ xxa No. 

a «r / 4 <f 
COPY ft 



Entered according to Act of Congress, in the year 1902, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 



c "■ * c - c c < 



WESTCOTT &. THOMSON, 
ELECTROTYPERS, PHILADA. 






TO 



^ 



HIS WIFE, 



WHO HAS SO FAITHFULLY AIDED IN ITS PREPARATION, 

THIS VOLUME 

is 
AFFECTIONATELY DEDICATED 

BY 

THE AUTHOR. 



PREFACE TO THE FOURTH EDITION. 



Within the five years spanned by the four editions of this book 
the practical importance of laboratory methods in clinical diagnosis 
has come to be widely appreciated. What share this work may have 
had in eifecting such an advance is not for the author to say. but he 
construes the growing demand for it as evidence that he has measur- 
ably succeeded in his effort to provide a plain and straightforward 
guide to those modern methods which at once facilitate and simplify 
the only certain path to success in practice, namely, accurate diag- 
nosis. With such methods at his command the obligation becomes 
binding, both legally and morally, to use them. Research, while 
constantly extending this field of knowledge, is also simplifying it, 
so that laboratory equipment is now not only a necessary but also a 
practicable part of every office. The physician can readily acquire a 
working grasp of precise diagnosis, and the student is finding it 
included in the greatly extended curriculum of a rapidly increasing 
number of colleges. To the needs of graduates and undergraduates 
alike this book is addressed. It endeavors to state the best methods 
clearly and simply, with all necessary instructions. Every effort has 
been made to render the book as modern and practical as possible. 

In preparing a new edition I have taken special pains to keep 
the volume thoroughly up to date, and have accordingly added 
much new matter which appeared to be of value. At the same 
time I have complied with the request of many medical friends 
to supply references to the literature on the subject. This has 
involved much labor, and has contributed materially to increase the 
size of the volume. To furnish a complete bibliography was, of 
course, out of the question, and I have necessarily been obliged to 
omit reference to many valuable papers. My endeavor has been to 
refer to articles which treat of the individual subjects in as exhaus- 
tive a manner as possible, and in which more detailed references to 
the literature can be found. These additions, I trust, will prove of 



vi PREFACE TO THE FOUETH EDITIOM 

value to the original worker and to the student, as well as to the 
teacher. 

One new colored plate and several engravings have been added. 
The plate, prepared by Mr. A. Horn, one of the artiste of Johns 
Hopkins Hospital, illustrates in a very satisfactory manner the 
various forms of leucocytes of the blood, and notably the deviations 
from the commonly pictured types of non-granular mononuclear 
cells which have so often seemed confusing. 

In conclusion, I must thank the profession for the kind rece] ti 
which has exhausted the large third edition in a fraction over a year. 
To the Publishers I desire to express appreciation of the painstaking 
care bestowed upon every detail of typography and illustration, as 
well as for many acts of courtesy. 

CHARLES E. SIMON. 

1302 M ADisoy Avevtz. 
Baltimore, Md. 



PREFACE TO THE FIRST EDITION. 



It is curious to note that, notwithstanding the great importance 
of clinical chemistry and microscopy, but little attention is paid to 
these subjects, either by hospital physicians or by those engaged in 
general practice. This lack of interest is referable primarily to the 
fact that a systematic study of these branches has hitherto been 
greatly neglected, not only in American medical schools, but also in 
those of Europe. 

It is no rarity to hear physicians in general practice claim that 
they are too busy to conduct careful examinations of the urine, 
sputum, blood, gastric juice, etc. Would it not be reasonable to 
suppose, however, that a physician who is overwhelmed with work 
to such an extent that he cannot find the time to make use of aids 
in diagnosis which are quite as important as the stethoscope, the 
laryngoscope, or the ophthalmoscope, would be in a position to 
employ an assistant in his laboratory ? The younger practitioner 
is certainly not placed in such a dilemma, and it is a fair assump- 
tion that he could successfully compete with his more experienced 
colleague, in matters of diagnosis at least, were he to familiarize 
himself sufficiently with laboratory methods of diagnosis. 

The time is at hand when the practice of medicine is becoming 
what it was long ago, but then unjustly, called, a true science and 
art. Xo continuing success can be built on empiricism or upon the 
proportion of guesswork which is inseparable from dependence upon 
" the experienced eye." " Diagnosis " is now the password in med- 
ical science. A knowledge of electro-diagnosis, of ophthalmoscopy, 
of laryngoscopy, etc., is at the present day a sine qua non for accu- 
rate diagnosis. Equally important at all times, and frequently even 
more important, is a knowledge of clinical chemistry and micros- 
copy. It is inconceivable that a physician can rationally diagnos- 
ticate and treat diseases of the stomach, intestines, kidneys, and 
liver, etc., without laboratory facilities. 



Vlll PREFACE TO THE FIRST EDITION. 

It has been the author's aim to present to students and physicians 
those facts in clinical chemistry and microscopy which are of practi- 
cal importance. With the hope of exciting interest in these unjustly 
neglected subjects, he has not confined himself to bare statements 
of facts, which must in themselyes be dry and uninteresting, but he 
has attempted to point out the reasons which haye led up to the 
conclusions reached. 

Chemical and microscopical methods are described in detail, so 
that the student and practitioner who has not had special training 
in such manipulations will be enabled to obtain satisfactory results. 

The subject-matter eoyers the examination of the blood, the secre- 
tions of the mouth, the gastric juice, feces, nasal secretion, sputum, 
urine, transudates, exudates, cystic contents, semen, yaginal dis- 
charges, and milk. In every case a description of normal material 
precedes the pathological considerations, which latter in turn are 
followed by an account of the methods used in examination. A 
glance at the table of contents will furnish an idea of the various 
subjects considered under each heading. 

In conclusion, it is the agreeable duty of the author to express 
his sincerest thanks to his wife for assistance without which this 
volume could not haye been written, and likewise for those illustra- 
tions which are original ; to Dr. AVilliam H. AVelch for his kind- 
ness in placing the former Hygienic Laboratory of the Johns 
Hopkins Hospital at his disposal during the years 1892 and 1893 ; 
to Dr. W. Milton Lewis for much yaluable aid in the correction of 
the manuscript and proof-sheets ; and to Messrs. Lea Brothers & 
Co. for the typographical excellence of the work, the extremely 
satisfactory reproduction of the drawings, and for many acts of 
courtesy. 

CHARLES E. SIMOX. 

Baltimore, Md., 1896. 



CONTENTS 



CHAPTER I. 
THE BLOOD 

PAGE 

General considerations 17 

General characteristics of the blood 17 

color 17 

odor 18 

specific gravity 18 

determination according to Roy 18 

determination according to Hammerschlag 19 

determination according to Schmaltz and Peiper 19 

indirect estimation of the haemoglobin 20 

estimation of the solids of the blood 20 

reaction 20 

estimation of the alkalinity accoz'ding to Landois-v. Jaksch 21 

estimation of the alkalinity according to Lowy 23 

estimation of the alkalinity according to Engel 24 

Chemical examination of the blood 25 

general chemistry of the blood 25 

blood-pigments 29 

haemoglobin 29 

oxyhaemoglobin 29 

estimation of haemoglobin with Fleischl's haemometer 32 

estimation of haemoglobin with Gowers' haemoglobinometer ... 35 

estimation of blood-iron with Jolles' ferrometer 36 

haemoglobinaemia 40 

carbon monoxide haemoglobin 41 

nitric oxide haemoglobin 42 

hydrogen sulphide haemoglobin 42 

carbon dioxide haemoglobin 42 

haematin 43 

haemin 44 

methaemoglobin , 44 

haematoidin 45 

hsematoporphyrin 45 

the spectroscope ... 46 

the proteids of the blood 47 

the carbohydrates 49 

sugar 49 

ix 



x CONTENTS. 

Chemical examination of the blood — Continued. page 

estimation of the sugar in the blood 50 

Williamson's diabetic blood test 50 

glycogen 51 

cellulose 52 

urea 52 

uraemia 53 

ammonia 53 

uric acid and xanthin-bases 53 

fat and fatty acids 55 

lactic acid 56 

biliary constituents . . . 57 

acetone 58 

Microscopical examination of the blood 58 

the red corpuscles 58 

variations in the size of the red corpuscles 58 

variations in the form of the red corpuscles 59 

variations in the number of the red corpuscles 60 

variations in the color of the red corpuscles 62 

behavior toward anilin dyes 63 

granular degeneration 65 

nucleated red corpuscles 67 

the leucocytes 69 

general differentiation of the various forms of leucocytes 69 

the auilin dyes 70 

differentiation of the leucocytes according to their behavior toward 

anilin dyes 71 

variations in the number of the leucocytes 80 

leucocytosis 80 

polynuclear neutrophilic hyperleucocytosis 81 

polynuclear eosinophilic hyperleucocytosis 89 

mixed hyperleucocytosis 91 

passive hyperleucocytosis (lymphocytosis) 93 

hypoleucocytosis (leukopenia) 94 

the drying and staining of blood 96 

staining with eosinate of methylene-blue (Jenner's stain) 99 

staining with Ehrlich's tri-acid stain 100 

staining with Aronsohn and Philip's modified tri-acid stain 100 

Neusser's stain 101 

staining with ha?matoxylin-eosin, or orange-G solution 101 

staining with Chenzinsky's eosin-methyiene-blue solution 101 

staining with Ehrlich's tri-glycerin mixture 102 

staining with Ehrlich's neutral mixture 102 

staining with eosin 102 

basic double staining 102 

staining with eosin-methylal and methylene-blue 103 

special staining of basophilic leucocytes 103 

Michaelis' eosin-methylene-blue stain 103 

distribution of the alkali in the blood 104 

the plaques 104 






CONTENTS. xi 

Microscopical examination of the blood — Continued. page 

the hremokonia, or dust particles of Miiller 105 

the enumeration of the corpuscles of the blood by the method of Thoma-Zeiss 105 

enumeration of the red corpuscles 106 

enumeration of the white corpuscles 108 

indirect enumeration of the leucocytes 109 

differential enumeration of the leucocytes 110 

enumeration of the plaques 110 

the hsematokrit 110 

Bacteriology and parasitology of the blood 113 

typhoid fever 114 

Widal's serum test 114 

pneumonia • 118 

sepsis 119 

anthrax 121 

acute miliary tuberculosis 121 

glanders 122 

influenza 122 

relapsing fever 123 

Malta fever 124 

yellow fever 124 

malaria 125 

filariasis 135 

distomiasis 136 

anguilluliasis 137 



CHAPTER II. 
THE SECRETIONS OF THE MOUTH. 

Saliva 138 

general characteristics 138 

chemistry of the saliva 138 

microscopical examination of the saliva 140 

pathological alterations 142 

Special diseases of the mouth 143 

tuberculosis of the mouth 143 

actinomycosis 143 

catarrhal stomatitis 143 

ulcerative stomatitis 143 

gonorrheal stomatitis 1 43 

thrush 144 

Tartar 144 

Coating of the tongue 144 

Coating of the tonsils 145 

pharyngomycosis leptothrica 145 

tonsillitis 145 

glandular fever 145 

diphtheria 145 



xii CONTENTS. 

CHAPTER III. 
THE GASTRIC JUICE AND THE GASTRIC CONTENTS. 

PAGE 

The secretion of gastric juice . 148 

Test-meals 149 

the test-breakfast of Ewald and Boas 149 

the test-dinner of Biegel 150 

the double test-meal of Salzer 1 50 

the test-breakfast of Boas 150 

The stomach-tube 150 

contraindications to the use of the tube 151 

introduction of the tube 151 

General characteristics of the gastric juice 153 

amount 153 

Chemical examination of the gastric juice 154 

chemical composition of the gastric juice 154 

the acidity of the gastric juice 155 

determination of the acidity of the gastric juice 157 

source of the hydrochloric acid 159 

significance of free hydrochloric acid 160 

the amount of free hydrochloric acid 162 

euchlorhydria 162 

hypochlorhydria 162 

anachlorhydria 162 

hyperchlorhydria 163 

test for free acids 163 

test for free hydrochloric acid 164 

the dimethyl-amido-azo-benzol test • 164 

the phloroglucin-vanillin test - 164 

the resorcin test 165 

the tropseolin test 166 

Mohr's test 166 

the ben zopurpurin test 166 

the combined hydrochloric acid 167 

quantitative estimation of the hydrochloric acid 168 

Topfer's method 168 

Martius and Luttke's method 170 

Leo's method 172 

the ferments of the gastric juice and their zymogens 173 

pepsin and pepsinogen 173 

tests for pepsin and pepsinogen 175 

quantitative estimation 176 

chymosin and chymosinogen 176 

tests for chymosin and chymosinogen 178 

quantitative estimation 178 

the products of gastric digestion 178 

digestion of the native albumins 178 

digestion of the proteids 179 

digestion of the albuminoids 179 

digestion of the carbohydrates 179 



CONTENTS. xiii 

Chemical examination of the gastric juice — Continued. page 

analysis of the products of albuminous digestion 181 

tests for the products of carbohydrate digestion 182 

lactic acid 183 

mode of formation and clinical significance 183 

tests for lactic acid 1 85 

Uffelmann's test 185 

Kelling's test 186 

Strauss' test 186 

Boas' test 187 

quantitative estimation of lactic acid according to Boas' method . . . 188 

the fatty acids 190 

mode of formation and clinical significance 190 

tests for butyric acid 191 

tests for acetic acid 192 

quantitative estimation of the fatty acids 192 

quantitative estimation of the organic acids 192 

gases 193 

acetone 195 

ptomai'ns and toxalbumins 195 

vomited material 196 

food-material 196 

mucus 197 

gastrosuccorrhcea mucosa 197 

saliva 198 

bile 198 

pancreatic juice 198 

blood ., 198 

test of Miiller and Weber 198 

Donogany's method 199 

pus 199 

stercoraceous material 199 

parasites 200 

odor 200 

Microscopical examination of the gastric contents 200 

the Boas-Oppler bacillus 201 

sarcina? 201 

shreds of mucous membrane 202 

tumor particles 203 

Examination of the motor power of the stomach 203 

Leube's method 204 

the salol test of Ewald and Sievers 204 

Examination of the resorptive power of the stomach 204 

Indirect examination of the gastric juice 205 

Gunzburg's method 205 

Simon's method 206 



XIV CONTENTS. 

CHAPTEE IV. 
THE FECES. 

PAGE 

Examination of normal feces 207 

general characteristics 207 

number of stools 207 

amount 207 

consistence and form 207 

odor 208 

color 208 

macroscopical constituents 208 

alimentary detritus 208 

foreign bodies 209 

microscopical constituents 209 

constituents derived from food 209 

morphological elements derived from the alimentary canal 210 

crystals 210 

parasites 212 

vegetable parasites 21 2 

fungi 212 

schizomycetes ' 212 

bacteria 213 

chemistry of normal feces 214 

reaction 214 

general composition 214 

phenol, indol, and skatol 216 

fatty acids 217 

cholesterin 218 

the biliary acids 219 

pigments 220 

Pathology of the feces 221 

general characteristics 221 

number of stools 221 

consistence and form 222 

amount 222 

odor 222 

reaction 223 

color 223 

macroscopical constituents 225 

alimentary constituents 225 

mucus and mucous cylinders 226 

biliary and intestinal concretions 227 

analysis of gall-stones 228 

microscopical examination 228 

technique 228 

remnants of food 2^9 

epithelium 2 ^0 

red blood-corpuscles 2 ^0 

mucus 23 ° 



CONTENTS. xv 

Pathology of the feces — Continued. page 

leucocytes 231 

crystals 231 

animal parasites 231 

protozoa 232 

Amoeba coli 233 

Cercomonas hominis 236 

Trichomonas intestinalis 236 

Megastoma entericum 237 

Balantidium coli 239 

vermes 239 

Taenia saginata 240 

Taenia solium 241 

Taenia nana 242 

Taenia diminuta 243 

Taenia cucumerina 243 

Bothriocephalus latus 243 

Krabbea grandis 245 

Distoma hepaticum 245 

Distoma lanceolatum 246 

Distoma Buskii 246 

Distoma sibiricum 246 

Distoma spatulatum 246 

Distoma conjunctum 246 

Distoma heterophyes 246 

Amphistomum hominis . . 246 

Ascaris lumbricoides 246 

Ascaris mystax 247 

Ascaris maritima 248 

Oxyuris vermicularis 248 

Anchylostomum duodenale 249 

Trichocephalus hominis 250 

Trichina spiralis 251 

Anguillula intestinalis 251 

insecta 252 

vegetable parasites 252 

bacillus of cholera 252 

Finkler-Prior bacillus 253 

typhoid bacillus 254 

tubercle bacillus 256 

Bacillus coli communis 256 

Bacillus lactis aerogenes 257 

Bacillus pyocyaneus 257 

Bacillus acidophilus 257 

Proteus vulgaris 258 

Bacillus dysenteriae 259 

Chemistry of the feces 260 

ptoma'ins 262 

The feces in various diseases of the intestinal tract 262 

acute intestinal catarrh 262 



xvi CONTESTS. 

The feces in various diseases of the intestinal tract — Continued. PAGE 

chronic intestinal catarrh 263 

cholera nostras 263 

summer diarrhoea of infants 263 

dysentery 264 

amoebic dysentery 264 

cholera Asiatica 265 

typhoid fever 265 

Meconium 265 

CHAPTER V. 

THE NASAL SECBETIOK 

Physiology and pathology of the nasal secretion 267 

CHAPTER VI. 
THE SPUTUM. 

General technique 269 

General characteristics of the sputa 270 

amount 270 

consistence 270 

color 271 

odor "271 

specific gravity 272 

configuration of sputa 272 

Macroscopical constituents of sputum 273 

elastic tissue 273 

fibrinous casts 273 

Curschmann's spirals 275 

echinococcus membranes 276 

concretions 276 

foreign bodies .' 276 

Microscopical examination 277 

leucocytes 277 

red blood-corpuscles 278 

epithelial cells 278 

elastic tissue 280 

animal parasites 281 

Taenia echinococcus 281 

Distoma pulmonale 283 

vegetable parasites 283 

pathogenic organisms 283 

the tubercle bacillus 283 

methods of staining 285 

Pappenheim's method 285 

Gabett's method 286 



CONTENTS. xv 11 

Microscopical examination — Continued. page 

Weigert-Ehrlich method 286 

Ziehl-Neelsen method 287 

the Diplococcus pneumoniae 287 

the bacillus of influenza 288 

the bacillus of whooping-cough •. . 288 

the smegma bacillus 288 

actinomycosis 289 

non-pathogenic organisms 290 

Oidium albicans 290 

Sarcina pulmonalis 290 

crystals . . . • 290 

Charcot- Ley den crystals 291 

haematoidin 291 

cholesterin 292 

fatty acid crystals 292 

leucin and tyrosin 292 

calcium oxalate 292 

triple phosphates 292 

Chemistry of the sputum 292 

The sputum in various diseases 293 

acute bronchitis 293 

chronic bronchitis 293 

putrid bronchitis and pulmonary gangrene 294 

fibrinous bronchitis 294 

bronchial asthma 294 

pulmonary abscess 294 

abscess of the iiver with perforation into the lung 295 

pneumonia 295 

phthisis pulmonalis 295 

oedema of the lungs 296 

heart-disease 296 

the pneumoconioses 296 

anthracosis 297 

siderosis 297 

chalicosis 297 

stycosis * 297 

CHAPTER VII. 

THE UEINE 

General considerations 298 

General characteristics of the urine 299 

general appearance 299 

color 300 

odor 301 

consistence 301 

quantity 301 

polyuria 302 

oliguria 305 



xvm yowTmm 

General characteristics of the urine — -G&mimmd. 

si'-riiz: t:;.t::t 

determination of the specific gravity 308 

determination of the solid constituents 310 

Lt.:::.: .; ; ; 

determination of the acidity of the urine 314 

FrenncFs method . 314 

Ciiemistry of the urine 315 

general chemical composition of the urine 315 

quantitative estimation of the mineral ash of the urine 316 

the chlorides 317 

:es: ::r :ld:r:de; in :de zzzzi i_. 

quantitative estimation of the chlorides by the method of Salkonrski- 

Volhard 320 

dire:: -z±:-i IL~ 

e~:i— s:i:r. ::' :r.e :l_l:ride= 2.':-: in lineri.:: : z sc-:-:rdizr :■: yezzize: 

and Salkowski j 325 

the phosphates 325 

test for die phosphates in the urine 330 

quantitative estimation of the total amount of phosphates .... 331 

separate estimation of the earthy and alkaline phosphates 331 

removal of the phosphates from the urine 334 

:Lr ^::i::s — 

:e?: :' : :~ze - zrz. :e- ::: :'..- zrize ::" 

quantitative estimation of the sulphates 338 

quantitative estima ti on of the total sulphates 338 

quantitative estimation of the conjugate sulphates 339 

neutral sulphur 34© 

quantitative estimation 342 

urea 343 

::r:rer::es ::' :'-:. • - : - : 

urea nitrate 352 

■;::, : z: is:e :••: : 

separation of urea from the urine 354 

quantitative estimation of urea 355 

estimation of nitrogen according to Kjeldahl 364 

estimation of nitrogen according to Wifl-Yarrentrapp 366 

ammonia 368 

:"..:::::: ::~t t-:_z:;.:: :z '■-•"■■■ 

Schlosing's method 369 

Folm's method ':". 

uric acid 37© 

:r:r. rr:ie= : : r: : .-.::£ '"- 

:es:s :.:ii 377 

quantitative estimation of uric acid 377 

- : ':'..::.:- ";: : ,-e- - •- - 

quantitative estimation 384 

hir ::::::.::: \ x . 

:r: :r::e= :::.':: ::r:: 2,:: i ^ 

-"-::":— e-:::. : :: ::' z'rrz*:: •.:■:£. ■ • ■:■*: 



CONTENTS. xix 

Chemistry of the urine — Continual. PAQE 

kreatin and kreatinin 388 

properties of kreatin and kreatinin 389 

test for kreatinin in the urine 390 

quantitative estimation of kreatinin in the urine 390 

oxalic acid 392 

properties of oxalic acid 394 

tests for oxalic acid 395 

quantitative estimation of oxalic acid 395 

Albumins 398 

serum-albumin 398 

Patein's or aceto-soluble albumin 409 

serum-globulin 409 

albumoses (peptones) 409 

Bence Jones' albumin , 411 

hemoglobin 412 

fibrin 414 

nueleo-albumin 414 

histon and nucleohiston 415 

tests for albumin 415 

tests for serum-albumin 416 

nitric acid test 416 

boiling test 419 

potassium ferrocyanide test 420 

trichloracetic acid test 420 

picric acid test 421 

Spiegler's test 421 

special test for serum-albumin 421 

quantitative estimation of albumin 422 

old method of boiling 422 

volumetric method of Wassiliew 422 

Esbach's method 423 

differential density method 423 

gravimetric method 424 

test for serum-globulin and its quantitative estimation 424 

tests for albumoses 425 

Salkowski's method 425 

Bang's method 426 

tests for Bence Jones' albumin 427 

tests for (mucin) nueleo-albumin 428 

tests for haemoglobin 428 

Heller's test 429 

the guaiacum test 429 

Donogany's test 430 

test for fibrin 430 

test for histon 430 

Carbohydrates 430 

glucose 430 

tests for sugar ... 438 

Trommer's test 4o9 



xx CONTENTS. 

Carbohydrates — Continued. page 

Fehling's test 439 

Bottger's test with Nylander's modification 440 

fermentation test 440 

phenylhydrazin test 441 

Kowarsky's modification 442 

polarimetric test 442 

quantitative estimation of sugar 444 

Fehling's method 444 

Knapp's method 446 

differential density method 447 

Einhorn's method 447 

Lohnstein's method 448 

polarimetric method 449 

Bremer's diabetic urine test 451 

lactose 452 

levulose 452 

maltose 452 

dextrin „ 452 

laiose 453 

pentoses 453 

Tollens' orcin test 453 

Tollens' phloroglucin test 453 

animal gum 454 

Glucuronic acid • 454 

Inosit 455 

Urinary pigments and chromogens 455 

normal pigments 455 

urochrome 455 

uroerythrin 457 

normal chromogens 458 

indican 458 

tests for indican 461 

quantitative estimation 462 

urohsematin 464 

uroroseinogen 465 

pathological pigments and chromogens 466 

blood-pigments 466 

hsematin 466 

urorubrohsematin and urofuscohsematin 466 

urohsematoporphyrin 466 

biliary pigments ■ 469 

Smith's test 470 

Huppert's test 470 

Gmelin's test (as modified by Kosenbach ) 471 

Gmelin's test 471 

biliary acids 471 

cholesterin 471 

pathological urobilin 471 

melanin and melanogen 474 



CONTENTS. xx i 

Urinary pigments and chromogens — Continued. pauk 

phenol urines 475 

alkapton 475 

homogentisinic acid 476 

blue urines 478 

green urines 478 

pigments referable to drugs 478 

Ehrlich's reaction 479 

Conjugate sulphates 482 

skatoxyl 482 

phenol 483 

Salkowski's test 483 

quantitative estimation 483 

pyrocatechin 484 

Acetone 484 

tests for acetone 486 

Legal's test 486 

Lieben's test 486 

Reynolds' test 486 

Dennige's test 486 

quantitative estimation 487 

Diacetic acid 489 

Arnold's test 489 

Oxybutyric acid 490 

Lactic acid 490 

Volatile fatty acids 491 

Fat 492 

chyluria 492 

galacturia 492 

Ferments 493 

Gases 493 

hydrothionuria 493 

Ptomains 494 

method of examination for ptomains , 495 

Sediments 496 

Microscopical examination of the urine 498 

non-organized sediments 500 

sediments occurring in acid urines 500 

uric acid . 500 

amorphous urates 502 

calcium oxalate 502 

ammonio-magnesium phosphate 504 

monocalcium phosphate 505 

neutral calcium phosphate 505 

basic magnesium phosphate 505 

hippuric acid 506 

calcium sulphate 506 

cystin 507 

leucin and tyrosin 508 

xanthin 511 



xxn CONTENTS. 

Microscopical examination of the urine — Continued. ' page 

soaps of lime and magnesia 512 

bilirubin and lisematoidin 512 

fat 512 

sediments occurring in alkaline urines 513 

basic phosphate of calcium and magnesium 513 

ammonium urate 513 

magnesium phosphate 513 

ammonio-magnesium phosphate 514 

calcium carbonate 514 

indigo 514 

organized constituents of urinary sediments 515 

epithelial cells 515 

leucocytes 518 

red blood-corpuscles 522 

tube-casts 525 

true casts . 526 

hyaline casts 526 

waxy casts . 526 

pseudo-casts 531 

cylindroids 531 

formation of tube-casts 531 

clinical significance of tube-casts 532 

spermatozoa 535 

parasites 536 

vegetable parasites 536 

animal parasites 542 

tumor particles .... 543 

foreign bodies 543 

CHAPTEK VIII. 

TKANSUDATES AND EXUDATES. 

Transudates 545 

general characteristics 545 

specific gravity 545 

chemistry of transudates 548 

microscopical examination 548 

Exudates 548 

serous exudates 549 

hemorrhagic exudates 549 

tuberculosis 549 

cancer 550 

putrid exudates 550 

pus 55 

general characteristics of pus 550 

chemistry of pus 551 

microscopical examination of pus 551 

leucocytes 5ol 



CONTEXTS. xxiii 

Exudates — Continued. faok 

giant corpuscles 552 

detritus 552 

red blood-corpuscles 552 

pathogenic vegetable parasites 553 

protozoa 553 

vermes 553 

crystals 553 

chylous and chyloid exudates 554 

CHAPTER IX. 

THE EXAMINATION OF CYSTIC CONTENTS. 

Cysts of the ovaries and their appendages 555 

test for metalbumin 555 

Hydatid cysts 557 

Hydronephrosis 557 

Pancreatic cysts 557 

CHAPTER X. 

THE CEREBROSPINAL FLUID. 

Definition 558 

Amount 559 

Appearance 559 

Specific gravity 560 

Reaction 561 

Chemical composition 561 

Microscopical examination 562 

Bacteriology • 562 

CHAPTER XL 

THE SEMEN. 

General characteristics 564 

Chemistry of the semen . 564 

Microscopical examination of the semen 565 

Pathology of the semen 566 

The recognition of semen in stains 566 

CHAPTER XII. 

VAGINAL DISCHARGES. 

General description 569 

Bacteriology 570 

Vaginal blennorrhea 571 



xxiv CONTENTS. 

PAGE 

Menstruation „ 571 

The lochia 571 

Vulvitis and vaginitis 572 

Membranous dysmenorrhea 572 

Cancer 572 

Gonorrhoea 572 

Abortion 573 

CHAPTER XIII. 

THE SECEETION OF THE MAMMAEY GLANDS. 

The secretion of milk in the newly born 575 

Colostrum 575 

The secretion of milk in the adult female 576 

Human milk , 576 

The milk in disease 577 

determination of the specific gravity 578 

estimation of the fat 580 

estimation of the proteids 580 



CLINICAL DIAGNOSIS. 



CHAPTER I. 
THE BLOOD. 

GENERAL CONSIDERATIONS. 

If blood is allowed to flow directly from an artery into a vessel 
surrounded by a freezing-mixture, and containing one-seventh its 
volume of a saturated solution of sodium sulphate, or a 25 per 
cent, solution of magnesium sulphate (1 volume to 4 volumes 
of blood), it will be observed that after some time a sediment, 
presenting the color of arterial blood, has formed at the bottom, 
which is covered by a layer of clear, straw-colored fluid — the blood- 
plasma. Upon microscopical examination the sediment will be seen 
to contain : 

<i. Numerous homogeneous, non- nucleated, circular, biconcave 
disks. These measure on an average 7.5 ft in diameter, and are of a 
faint greenish-yellow color when viewed through a microscope, 
while en masse they present the color of arterial blood — the erythro- 
cytes or red corpuscles of the blood. 

b. Roundish or irregularly shaped nucleated cells which are far 
less numerous than the red corpuscles, and devoid of coloring-matter 
— the leucocytes, colorless or white corpuscles of the blood. 

c. Minute colorless disks, measuring less than one-half the di- 
ameter of a red corpuscle — the so-called blood-plaques, or blood- 
plates of Bizzozero. 

GENERAL CHARACTERISTICS OF THE BLOOD. 

The Color. 

Chemical examination of the blood shows that its color is ref- 
erable to the presence of an albuminous, iron-containing substance — 
haemoglobin — in the bodies of the red corpuscles, which is characterized 
by its great avidity for oxygen, and forms a compound therewith, 
known as oxyhemoglobin. The relatively larger amount of the 

2 17 



18 THE BLOOD. 

latter encountered in the arteries, as compared with the veins, causes 
the difference in the appearance of arterial and venous blood, the 
former presenting a bright scarlet-red, the latter a dark -bluish color. 
A bright cherry -red color is noted in cases of poisoning with carbon 
monoxide, while a brownish-red or chocolate color is observed in 
cases of poisoning with potassium chlorate, anilin, hydrocyanic 
acid, and nitrobenzol. A milky appearance is frequently seen in 
cases of well-marked leuksemia. In chlorosis and hydrsemic con- 
ditions, as would be expected, the blood is pale and watery. 

The Odor. 

The peculiar odor of the blood, which varies in different animals, 
the halitus sanguinis of the ancients, is due to the presence of 
certain volatile fatty acids, and may be rendered more distinct by 
the addition of concentrated sulphuric acid. 

The Specific Gravity. 

The specific gravity of the blood in healthy adults varies between 
1.058 and 1.062, being higher on an average in men, 1.059, than 
in women, 1.056, and children — boys 1.052, girls 1.050. It is 
diminished to a certain extent by fasting, the ingestion of solids and 
liquids, gentle exercise, pregnancy, etc. The specific gravity, 
moreover, depends upon the bloodvessel from which the specimen 
is taken, being higher, generally speaking, in venous than in arterial 
blood. 

Under pathological conditions the specific gravity may vary 
between 1.025 and 1.068. In nephritis, chlorosis, the ansemias in 
general, and in cachectic conditions (pulmonary phthisis, carcinoma 
of the stomach, etc.) it may diminish to 1.031. An increased 
specific gravity is met with in febrile diseases (typhoid fever, 1.057 to 
1.063), conditions associated with pronounced cyanosis (emphysema, 
fatty heart, uncompensated valvular disease, 1.054 to 1.068), and 
obstructive jaundice, 1.062. 

Methods of determining the Specific Gravity of the 

Blood. 

Roy's Method. — A number of test-tubes are filled with a mixt- 
ure of glycerin and water in different proportions, so that the specific 
gravity in the different tubes varies between 1.025 and 1.068. 
Blood' is then drawn from the tip of a finger, or the lobe of the ear, 
into a capillary tube connected with an ordinary hypodermic syringe, 
pressure being avoided. A drop of blood is placed in each tube, in 
which it wilt sink as long as the specific gravity of the glycerin 
mixture is lower than that of the blood, while it will remain sus- 



GENERAL CHARACTERISTICS OF THE BLOOD. 19 

pended in a mixture the specific gravity of which is equivalent 

to its own. 

Roy states thai it is important for the purpose of comparison to 
make such examinations in each case at the same hour, as the spe- 
cific gravity of the blood has been shown to undergo diurnal varia- 
tions. 

Hammerschlag's Method. — A cylinder, measuring about 10 cm. 
in height, is partly rilled with a mixture of chloroform (sp. gr. 1.526) 
and benzol (sp. gr. 0.889), having a specific gravity of 1.050 to 
1.060. Into this solution a drop of blood is allowed to fall 
directly from the finger, pressure being avoided, and care taken 
that the drop does not come in contact with the Avails of the vessel. 
The drop, moreover, should not be too large, as otherwise it will 
separate into droplets, giving rise to inaccurate results. Should 
the drop sink to the bottom, it is apparent that the specific gravity 
of the mixture is lower than that of the blood, necessitating 
the addition of chloroform. This should be added drop by drop 
while the mixture is thoroughly stirred. If, on the other hand, the 
drop should tend toward the surface, it is best to add an amount of 
benzol sufficient to cause the blood to sink to the bottom, and then to 
bring it to the proper degree of suspension by the subsequent addi- 
tion of chloroform. As soon as the drop remains suspended the 
mixture is filtered, and its specific gravity ascertained by means of 
an accurate areometer registered to the fourth decimal. The figure 
obtained is the specific gravity of the blood. The chloroform- 
benzol mixture may be kept indefinitely. 

With practice, results sufficiently accurate for clinical purposes 
may thus be obtained with an expenditure of very little time. 

Schmaltz and Peiper's Method. — Where delicate scales are avail- 
able the method of Schmaltz and Peiper may be employed, and is 
certainly the most accurate : a capillary tube, measuring about 12 
cm. in length and 1.5 mm. in width, with its ends tapering to a 
diameter of 0.75 mm., is filled with blood and carefully weighed, 
when the weight of the blood, divided by the weight of an equiva- 
lent volume of distilled water, will indicate the specific gravity. 

As the result of numerous investigations it may now be regarded 
as an established fact that with the exception of nephritis, circulatory 
disturbances, leukaemia, and possibly also post-hemorrhagic anaemia 
and that resulting from inanition, the specific gravity of the blood 
varies directly with the amount of haemoglobin. A simple method is 
thus given by means of which haemoglobin estimations can usually be 
made in the absence of more expensive instruments. In the follow- 
ing table the specific gravities, as obtained with Hammerschlag's 
method, and that of Schmaltz and Peiper, are given, with the corre- 
sponding amounts of haemoglobin. The figures, however, are prob- 
ably not quite accurate : 



20 TEE BLOOD. 

Specific gravity Specific gravity 

according to Haemoglobin. according to Haemoglobin. 

Hammerschlag. Schmaltz and Peiper. 

1.033-1.035 . . . 25-30 per cent. 1.030 20 per cent. 

1.035-1.038 . . . 30-35 " 1.035 30 " 

1.038-1.040 . . . 35-40 " 1.038 35 " 

1.040-1.045 . . . 40-45 " 1.041 40 " 

1.045-1.048 . . . 45-55 " 1.0425 45 " 

1.048-1.050 . . . 55-65 " 1.0455 50 " 

1.050-1.053 . . . 65-70 " 1.048 ..... 55 " 

1.053-1.055 . . . 70-75 " 1.049 60 " 

1.055-1.057 . . . 75-85 " 1.051 65 " 

1.057-1.060 . . . 85-95 " 1.052 70 " 

1.0535 75 " 

1.056 80 " 

1.0575 90 " 

1.059 100 " 

Literatuee. — Schmaltz, Deutsch. Arch. f. klin. Med., vol. xlvii. p. 145; and 
Deutsch. med. Woch., 1891. No. 16. Stintzing u. Gumprecht, Deutsch. Arch. f. klin. 
Med., vol. liii. p. 265. Siegl, Prag. med. Woch., 1892, No. 20 ; and Wien. med. Woch., 
1891, No. 33. Hammerschlag, Ibid., 1890, p. 1018; and Zeit. f. klin. Med., 1892, vol. 
xxii. p. 475. Schmaltz, Deutsch. Arch. f. klin. Med., 1890, vol. xlvii. p. 145 ; and 
Deutsch. med. Woch., 1891, vol. xvii. p. 555. 

Direct Estimation of the Solids of the Blood. 

A few drops of blood (0.2 to 0.3 gramme), obtained by means of 
a fairly deep incision or puncture into the tip of a finger, moderate 
pressure being made upon the middle phalanx if necessary, are col- 
lected in a watch-crystal. This is at once covered with its fellow 
and weighed. The specimen (open) is then dried at a temperature 
of from 60° to 70° C. for twenty-four hours, and again weighed, 
the weight of the solids being thus ascertained. 

In healthy adults the following values were obtained by Stintzing 
and Gumprecht : 

Average. Maximum. Minimum. Average water. 

In men 21.6 23.1 19.6 78.4 per cent. 

In women 19.8 21.5 18.4 80.2 

In conditions associated with chronic anaemia the solids, as would 
be expected, are always much diminished. In leukaemia, on the 
other hand, owing to the large number of leucocytes present, a rela- 
tive increase is observed. 

The Reaction. 

The reaction of the blood during life, owing to the presence of 
disodium phosphate and sodium carbonate, is alkaline, the degree of 
alkalinitv in terms of sodium hydrate under normal conditions cor- 
responding to 182 to 218 mgrms. for every 100 c.c. of blood, v. 
Jaksch gives 260 to 300 mgrms. as the normal, and Canard 203 to 
276 mgrms. 



GENERAL CHARACTERISTICS OF THE BLOOD. 21 

The alkaline reaction of the blood may be demonstrated by re- 
peatedly drawing a strip of red litmus-paper, thoroughly moistened 
with a concentrated solution of common salt, through the blood, 
and rapidly washing off the corpuscles with the same solution, when, 
as a genera] rule, the alkaline reaction can be clearly made out. 

Small plates of plaster of Paris or clay, stained with neutral 
litmus solution, may be similarly employed, the blood in this ease 
being washed off with water. 

Generally, the alkalinity of the blood is low r er in women and 
children than in men, and is, furthermore, influenced by the proc- 
ess of digestion, exercise, etc. At the beginning of digestion, 
when hydrochloric acid is being freely secreted, the alkalinity of 
the blood increases ; while later on, when both hydrochloric acid 
and peptones are reabsorbed, the alkalinity in turn diminishes. 
Higher values are usually found during pregnancy than in the non- 
pregnant state. 

A decrease is observed following violent muscular exercise, such 
as forced marches by soldiers, owing, in all probability, to an exces- 
sive production of acids in the muscles. 

Under pathological conditions a diminished alkalinity of the blood 
is frequently observed. This is particularly marked in cases of 
severe anaemia (108 to 145 mgrms. of NaOH), and increases as the 
number of red corpuscles and the amount of haemoglobin diminish. 
Iu chlorosis, however, the diminution in the number of red corpus- 
cles is accompanied by a normal, or but slightly diminished, alkalinity 
of the blood as a whole. In leukemia, pernicious anaemia, nephritis 
when accompanied by uraemia, various hepatic affections, diabetes, 
carcinoma, the various profound cachexiae, pseudoleukaemia, poison- 
ing with carbon monoxide and acids, and finally in highly febrile 
conditions, as in typhoid fever, and toxic processes in general, the 
alkalinity of the blood is diminished, the lowest value found corre- 
sponding to 108 mgrms. of NaOH. A similar decrease follows the 
prolonged use of acids, while an increase is brought about by the 
ingestion of alkalies. An increase in the alkalinity of the blood 
occurs after a cold bath, and it is interesting to note that this is 
aj >parently associated with an increase in the bactericidal power of 
the blood. Possibly the beneficial effect of cold baths in fever 
may be explained upon this basis. The supposition that in gout 
a diminished alkalinity exists between the attacks, and that this 
increases beyond the normal during the attack, has been proved 
unfounde 1. 

v. Jaksch employs the following method, a modification of that 
originally devised by Landois : eighteen watch-crystals are prepared, 
each containing a mixture of a concentrated solution of sodium 
sulphate and a y^- and a y-jyVir normal solution of tartaric acid, in 
varying proportions, so that crystal 



22 












THE 


BLOOD. 




No. 






C.c. 










C.C. 


I. 


Shall contain 0.9 of th 


e To "o 


norm. 


sol. of the acid, 


and 0.1 


II. 


" 




0.8 


'< 




" 


" '• 


'•' 0.2 


III. 


u 


" 


0.7 


" 


" 


" 


" " 


" 0.3 


IV. 


« 


a 


0.6 


'• 


" 


« 


it u 


u 0.4 


V. 


It 


" 


0.5 


" 


" 


" 


it u 


" 0.5 


VI. 


(( 


(( 


0.4 


" 


" 


a 


(I u 


" 0.6 


VII. 

mi. 


it 
u 


u 


0.3 
0.2 


« 


u 


u 




" 0.7 
" 0.8 


IX. 


(( 


u 


0.1 


" 


" 


" 


n a 


li 0.9 


X. 


<< 


" 


0.9 


" 


TOCTo" 


" 


k a 


" 0.1 


XI. 


" 


" 


0.8 


" 




u 


a « 


" 0.2 




etc., 


for eacl 


L C.C. 


of the mixture. 







Blood is taken, preferably from the back, by means of cupping- 
glasses, and, before it coagulates, 0.1 c.c. is added to each c.c. of 
the mixture described, when the reaction is determined in each 
crystal by means of very sensitive litmus-paper. The amount of 
acid contained in the specimen exhibiting a neutral reaction in terms 
of ^NaOH will then indicate the degree of alkalinity of the blood. 

As 150 (molecular weight) parts by weight of tartaric acid (C 4 H fi 6 ) 
combine with 80 (molecular weight) parts by weight of XaOH, or 
75 with 40, according to the equation : 

/COOH /COONa 

C 2 H 2 (OH) 2 < - 2XaOH = C 2 H 2 ' OH) 2 < + 2H 2 0, 

"\COOH x COOXa 

a normal solution would contain 75 grammes of pure tartaric acid 
to the liter and a yi^ and a 1Q \ normal solution, respectively, 0.75 
and 0.075 gramme. As 1000 c.c. of a y^- normal solution would 
correspond to 0.4 gramme of XaOH, and 1000 c.c. of a -j-jnnr nor ~ 
mal solution to 0.04 gramme, 1 c.c. of the T | ¥ normal solution will 
represent 0.0004, and 1 c.c. of the 1 \ normal solution 0.00004 
gramme of XaOTT. 

Supposing, then, that a neutral reaction was obtained in the crystal 
containing 0.6 c.c. of the y^ normal solution, the alkalinity of the 
0.1 c.c. of blood in terms of ISaOH would correspond to 0.00024 
gramme of XaOH, or 0.24 gramme for 100 c.c. of blood. 

As the alkalinity of the blood rapidly diminishes after being 
drawn, owing, in all probability, to the formation of an acid caused 
by decomposition of the haemoglobin, it is apparent that the ex- 
periment must be performed as rapidly as possible, and not more 
than one minute and a half should elapse between the taking of the 
blood and the conclusion of the experiment. 

This method has hitherto been the onlv one which was available 
for clinical purposes, and the results detailed above have been 
obtained by its aid. It is open to numerous objections, however, 
and is too complicated for routine work. Of late, a new method, 
suggested by Lowy, has attracted much attention, and, to judge 



GENERAL CHARACTERISTICS OF TEE BLOOD. 23 

from the Literature, is destined soon to replace the one described. 

It is both simpler and more accurate. The results, however, differ 
considerably from those given above, and a careful revision of the 
work thus far accomplished with the old method will be necessary 

before definite conclusions can be reached. For the convenience of 
future investigators a table is here appended containing some of 

the results obtained in some of the more important diseases. In 
healthy adults, while fasting, the alkalinity of the blood, according 
to Lowy, corresponds to about 300 to 325 mgrms. of sodium 
hydrate for every 100 c.c. of blood. Variations, amounting to To 
mgrms., plus or minus, are, however, not uncommon, and, according 
to Strauss, the unavoidable errors may correspond to 30 mgrms. : 

Carcinoma oesophagi 227-643 

Carcinoma ventriculi 256-635 

Ulcus ventriculi 302-460 

Anadeny of the stomach 354-360 

Alcoholic gastritis 343-379 

Chronic enteritis 212-272 

Phthisis pulmonalis 450-468 

Bronchitis 239-343 

Neurasthenia 225-426 

Arteriosclerosis 208-344 

Chronic arthritis 368-465 

Ervsipelas 498 

Typhoid fever 270-640 

Pneumonia 263-464 

Septicaemia 443 

Leukaemia . . 368-835 

Pernicious anaemia 429 

Diabetes mellitus 362-457 

Chronic interstitial nephritis 310-409 

Chronic parenchymatous nephritis 312-490 

Cirrhosis of the liver 272-345 

Lowy's Method. — Five c.c. of blood, obtained from one of the 
superficial veins of the arm (preferably the median cephalic), are 
allowed to flow into a small flask provided with a long and partially 
graduated neck, and containing 45 c.c. of a 0.25 per cent, solution 
of ammonium oxalate. Coagulation is thus prevented and the blood 
made lake-colored — i. e., the haemoglobin is dissolved from the 
stroma of the red corpuscles. The mixture is then titrated with a 
-^ normal solution of tartaric acid, using lacmoid paper, soaked in a 
concentrated solution of magnesium sulphate, as an indicator. The 
lacmoid paper is prepared as follows : 

A mixture of 100 grammes of resorcin, 5 grammes of sodium 
nitrite, and 5 c.c. of distilled water, is heated on an oil-bath to a 
temperature of 110° C. A violent reaction occurs at this point, and 
the flame should be removed before it is reached. The substance 
is then heated to a temperature of 115°-120° C. until all the am- 
monia which is evolved during the process has been driven off. The 
residue, which should be of a pure blue color, is dissolved in water 



24 



THE BLOOD. 



and precipitated with hydrochloric acid. On cooling, the coloring- 
matter is filtered off with the aid of a suction-pump, and washed 
with a little water. It is then dissolved in absolute alcohol, filtered, 
and the solution allowed to evaporate in an atmosphere free from 
ammonia. One gramme of the pigment, which crystallizes in 
reddish-brown, glistening platelets, is dissolved in 1000 c.c. of 45 
per cent, alcohol ; in this solution strips of fine Swedish filter-paper 
are soaked and then allowed to dry. 

As a normal solution of tartaric acid contains 75 grammes to the 
liter (see page 22), a -^ normal solution will contain 3 grammes, 
and 1 c.c. of the -gV normal solution will correspond to 0.0016 
gramme of sodium hydrate. 

Supposing, then, that 10 c.c. of the -^ normal solution were 
necessary to neutralize the 5 c.c. of blood, the alkalinity of these 5 
c.c. in terms of sodium hvdrate would correspond to 0.016 gramme, 
and the alkalinity of 100 c.c. of blood to 0.016 X 20 = 0.320 
gramme — i. <?., to 320 mgrms. 

Engel's Method. — This is essentially a modification of Lowy's 
method, and is well adapted for clinical purposes, as the amount of 
blood which is required for a single examination can readily be 
obtained by ordinary puncture. 

Fig. 1. 




Ensrel's alkalimeter. 



The blood is measured and rendered lake-colored in a specially 
constructed pipette (Fig. 1). To this end, the blood is drawn to 
the 0.05 c.c. mark and diluted with neutral, distilled water, so that 
the volume of the mixture reaches the 5 c.c. line. After slight 



CHEMICAL EXAMINATION OF THE B Loon. 25 

agitatioo the solution is placed in a small beaker and is titrated 
with a J% normal solution of tartaric acid, from a special burette 
which accompanies the pipette. This is so constructed thai each 

cubic centimeter is divided into twenty parts. Before and alter the 
addition of every drop of the titrating fluid the reaction of the 
mixture is tested by placing a drop upon Lowy's lacmoid paper (see 
above). The end-reaction is reached when the yellow drop of the 
blood mixture shows a distinct red line along the margin. The result 
is expressed in terms of milligrammes of sodium hydrate per 1 e.c. 
of blood. Normally about 10 c.c. of the acid solution are em- 
ployed. The tartaric acid solution contains 1 gramme to the liter, 
so that 1 e.c. corresponds to 0.533 mgrm. of sodium hydrate. 

Supposing that 0.6 c.c. of the acid solution was required to neu- 
tralize the 0.05 c.c. of blood, then 12 c.c. would be necessary for 
1 c.c. of blood. As 1 c.c. of the acid solution represents 0.533 
mgrm. of sodium hydrate, the alkalinity of 1 c.c. of blood would 
correspond to 12 X 0.533 — i. e., to 6.396 mgrms. 

Literature. — v. Jaksch, Zeit. f. klin. Med., 1887, vol. xiii. p. 350. A Lowy, Arch, 
f. (1. gesammte Physiol., 1394, vol. lviii. p. 462. Lowy u. Richter, Deutsch. med. Woch., 
1895, vol. xx. p. o26. Peiper. Arch. f. path. Anat., 1889, vol. cxvi. p. 337. Rumpf, 
Centralbl. f. inn. Med.. 1891, vol. xii. p. 447. Kraus, Arch. f. exp. Path. u. Pharinakol., 
vol. xxvi. Engel. Berlin, klin. Woch.. 1S93, p. 308. 

CHEMICAL EXAMINATION OF THE BLOOD. 

General Chemistry of the Blood. 

A general idea of the chemical composition of the blood may be 
formed from the accompanying table of C. Schmidt, 1 calculated for 
1000 parts: 

Man. Woman. 

Corpuscles 513.00 2 369.20 

Water 349.70 272.60 

ILemoglobin and globulins 159.60 120.10 

Mineral salts 3.70 3.55 

Plasma 486.90 603.80 

Water 439 00 552.00 

Fibrin 3.90 1.91 

Albumins and extractives 39.90 44.79 

Mineral salts 4.14 5.07 

If blood is allowed to flow into a vessel and set aside, it will be 
observed at the expiration of a few minutes that the entire mass has 
become transformed into a semisolid, gelatinous material, which is 
spoken of as the blood-clot or the placenta sanguinis. Still later 
it will be seen that a small amount of straw-colored fluid appears 
on top of the clot, which gradually increases in amount, while the 

1 Cited by v. Gorup-Besanez. Lehrb. d. physiol. Chem., 4th ed., p. 345. 

2 This figure is too hi^h ; in man it varies between 420 and 470 for 1000 parts of 
blood. 



26 THE BLOOD. 

clot itself undergoes shrinkage, until finally it floats, greatly dimin- 
ished in size, in the surrounding fluid. The straw-colored fluid 
which has thus been obtained during the process of coagulation is 
spoken of as the blood-serum. 

If a bit of the clot is examined microscopically, it will be seen to 
consist of a more or less dense network of fibres, the meshes of which 
are filled with blood-corpuscles, which may be washed out, leaving 
the fibrous network, fibrin, behind. 

Chemically speaking, fibrin belongs to the class of the so-called 
coagulated albumins ; : as not occur in the circulating blood, but 
is : raied only during the process of coagulation. 

The albumins which are found in the plasma are fibrinogen, serum- 
globulin, and serum-albuniin. but while the last two are likewise 
encountered in the serum, the fibrinogen has disappeared, and traces 
of a new albuminous body, fibrin o-globulin, are found. There ap- 
pears to be no doubt that fibrin results from the fibrinogen by a proc- 
ss : liss iation. and that the traces of fibrino-globulin are formed 
at that time. Modern research, furthermore, has shown that the 
transformation of fibrinogen into fibrin is dependent upon the action 
of a special ferment, the fibrin ferment, which is derived in all 
probability from the leuc-: cytes : the blood by a process of plasm o- 
schisis. The presence of serum-globulin apparently hastens coagu- 
lation in an indirect manner, as is done by calcium chloride and the 
calcium salts in general. 

Under normal conditions blood clots in from tw< tc six minutes 
after being shed, while in disease, notably in haemophilia, coagnla:" 
may be greatly retarded or does not < cur at all. so that fatal hemor- 
rhage may follow the infliction of trifling wounds. Whether or not 
this condition is referable to abnormalities in the chemical compo- 
shaon of the blood is as yet undetermined. 

A tendency to heniorrhag is als observed in scurvy, purpura, in 
some infectious diseases, such as typhoid fever and yellow fever, in 

nsoning with phosphorus, etc. 1 Sicard- has recently pointed out 
that in purpura primary coagulation occurs as with aormal blocd, 
but that subsequent retraction of the clot and exudation of serum take 
place to only a very limited extent, formal serum when added to 
fluids, such as hydrocele fluid, which are not spontaneously coagula- 
ble, in the proportion of 1 : 80, induce coagulation in from four to :: 
hours. The serum of purpuric patients, on the other hand, is either 
enti: id of this property or possesses it to only a very slight 

degree. The addition of a trace of calcium chloride, ho* uses 

such serum to behave very much like normal serum. Sicard L 
suggests that in certain cases of purpura the fibrin ferment, or Ha 

1 Schmidt, Pfluger's Archiv. vol. xi. pp. 291 and 515. Bojanns. Inang. Diss.. Dorpat,' 

2 Sicard. Compt. rend. soe. biolog-. vol. li. p. 579. 



CHEMICAL EXAMINATION OF Till-: BLOOD. 27 

pro-enzyme is not present in sufficient quantity to cause more than a 

primary coagulation. Subsequent retraction, however, may also be 
due to the action of another variety of fibrin, the zymogen of which 

is absent in purpura. 

Since the formation of fibrin begins as soon as the blood has left 
its natural channels, it is apparent that absolutely accurate analyses 
of blood-plasma can hardly be expected. The appended analyses of 
the plasma of the horse's blood arc taken from Hoppe-Seyler and 
Hammarsten, the figures having reference to 1000 parts : 

Water 90S.4 917.6 

Solids 91.6 82.4 

Total albumins 77.6 69.5 

Fibrin 10.1 6.5 

Globulin 38.4 

Serum-albumin 26.4 

Fat 1.2 1 

Extractives 4.0 ! , OQ 

Soluble salts 6.4 1A * 

Insoluble salts 1.7 J 

The chief points of difference between plasma and scrum are the 
absence of fibrinogen and the presence of traces of fibrino-globulin, 
as well as of large quantities of fibrin ferment, in the latter. 

From the following table it will be seen that a marked difference 
exists in the nature of the mineral ingredients between serum and 
the red corpuscles, the latter being relatively rich in potassium salts 
and phosphorus, and poor in sodium salts and chlorine. The figures 
have reference to 1000 parts of blood : 

Man. Woman. 

Red '~Red 

corpuscles. Serum. corpuscles. Serum. 

K,0 1.5S6 0.153 1.412 0.200 

Na. 2 0.241 1.061 0.648 1.916 

Cat) 

MgO 

Fe 2 5 

CI 0.898 1.722 0.362 1.440 

PA 0.695 0.071 0.643 2.202 

It is noteworthy that the amount of sodium chloride in the serum, 
6 to 7 pro mille, remains fairly constant no matter whether 
large amounts are ingested or none at all is given. It is probable 
that the sodium chloride of the plasma serves the purpose of pro- 
venting the haemoglobin of the corpuscles from being dissolved by 
the water of the blood. The term "isotonic" has been applied by 
Hamburger 1 to a salt solution which is just strong enough to pro- 
vent the solvent action of the water upon the haemoglobin of the red 

1 Hamburger. Zeit. f. Biol., vol. xxvi. p. 414 ; Ibid., vol. xxvii. p. 259 ; and Virchow's 
Arcbiv, vol. cxl. p. 503. 



28 THE BLOOD. 

corpuscles. In the case of the serum, however, we meet with a 
condition of hyperisotonia — i. e., an amount of salt in excess of that 
actually required in order to prevent the destruction of the red 
corpuscles, the advantage of which is, of course, apparent, if the 
variations to which the amount of water in the blood is subject are 
borne in mind. 

In addition to the substances mentioned, the following are also 
found in the blood : 

Fat occurs in amounts varying from 1 to 7 pro mille in fasting 
animals, while following the ingestion of a meal rich in fats as much 
as 12.5 pro mille have been encountered. 

Soaps, cholesterin, and lecithin have likewise been found. 

Sugar, probably glucose, appears to form a normal constituent of the 
plasma, amounting to from 1 to 1.5 pro mille in man. AVhile it is 
possible to increase this amount to a certain degree by the ingestion 
of large quantities of sugar, this appears in the urine, according to 
Claude Bernard, as soon as 3 pro mille have been exceeded. In addi- 
tion to glucose, another reducing substance has been found in the blood, 
which differs from the former in not being fermentable. According 
to recent researches of P. Mayer. 1 this is in all probability a glucu- 
ronic acid compound. ^Whether jecorin also occurs in the blood is 
doubtful. 

Among the extractives which have been found, there may be men- 
tioned urea, uric acid, kreatin, carbamic acid, sarcolactic acid, gly- 
cogen, and hippuric acid, and under pathological conditions xanthin, 
hvpoxanthin. paraxanthin. adenin. guanin, leucin. tyrosin, lactic acid, 
cellulose, ^-oxybutyric acid, acetone, and biliary constituents. 

It has been pointed out that the color of the blood is referable to 
the presence of haemoglobin in the red corpuscles, and that it varies 
from a bright scarlet-red in the arteries to a dark bluish-red in the 
veins, the exact shade depending upon the amount of oxygen present 
in combination with haemoglobin as oxyhemoglobin. Upon chemical 
examination two other gases may be demonstrated under physiological 
conditions, viz.. carbon dioxide and nitrogen. Of these, the latter 
appears to play no part in the body-economy, and the amount present 
merely corresponds to that which would be absorbed by an equal 
volume of distilled water, viz., 1.8 vol. per cent., calculated at C C. 
and 760 Hgrom. pressure. 

The amount of oxygen and carbon dioxide, on the other hand, 
undergoes considerable variation, depending upon the particular 
bloodvessel from which the specimen is taken — i. e.. whether this be 
an artery or a vein. and. furthermore, upon the velocity of the blood- 
current, the temperature of the body, rest, exercise, etc. 

The relation existing between the amounts of these gases in arteries 
and veins may be seen from the following table : 

1 P. Mayer. Zeit. f. physiol. Chem.. vol. xxxii. p. 515. 



CHEMICAL EXAMINATION OF THE BLOOD. 29 

Arterial blood. Venous blood. 

Oxygen 21.6 percent. 6.8 per cent. 

Carbon dioxide 40.3 " 48.0 " 

Nitrogen 1.8 " 1.8 « 

Oxygen, as already pointed out, occurs principally in chemical 
combination with haemoglobin (oxyhemoglobin), only 0/26 per cent. 
being present in solution in the plasma. 

Of the carbon dioxide which may be obtained from the blood, 
only one-tenth is held in solution, while the remaining portion is 
found in the red corpuscles, in the form of a loose compound with 
the alkalies of the corpuscles, and possibly also in combination with 
haemoglobin. This portion amounts to about one-third of the total 
quantity, while the remaining two-thirds are probably held in chem- 
ical combination by the alkalies of the plasma and certain albuminous 
bodies. 

Blood-pigments. 

Haemoglobin. — Haemoglobin as such is found in relatively small 
amounts in the circulating blood, occurring essentially in com- 
bination with oxygen as oxyhemoglobin, which predominates in 
arterial blood, while a mixture of oxyhaemoglobin and haemoglobin 
is met with in venous blood, and haemoglobin is present almost 
exclusively in the blood of asphyxia. 

The spectrum of haemoglobin, in suitable dilution, shows a single 
band of absorption between D and E, which, however, does not lie 
midway between these lines, but extends slightly beyond B to the 
left (Fig. 2). The substance is characterized by the ease with which 
it forms compounds with certain gases, and notably so w T ith oxygen. 

Fig. 2. 
Red Orange Yellow Green Qian-blue 

A a B C I) ^~ Eb F ~~~ 

40 50 60 70 80 90 100 110 



LLil 



1 1 11 1 , 1 1 1 1, 1 1 1 1 



■ 1 1 1 1 1 1 1 1 1 1 1 ij.i l«'1.'.<.i_l_L J_l _l '.I..I.1 1 1 j 1 1 1 1 1 1 1 1 1 1 1 1 




I 



IiiiiIiiiiIi in 



Spectrum of reduced haemoglobin, (v. Jaksch.) 

As stated above, carbon dioxide, to a certain extent at least, also 
occurs in combination with haemoglobin. In cases of poisoning, 
compounds of haemoglobin with carbon monoxide, with nitric oxide, 
and possibly also with hydrogen sulphide, cyanogen, and acetylene, 
have been observed. 

Oxyhemoglobin. — Oxy haemoglobin is the most important constit- 
uent of the blood. In sufficiently dilute solution it shows two bands 
of absorption between D and E ; one band, a, which is not so wide 



30 



THE BLOOD. 



as the second, p, but darker and more sharply defined, borders on D, 
while the second, which is wider, but less sharply defined, lies at E 
(Fig. 3). This spectrum can be readily transformed into that of 
haemoglobin by the addition of a reducing agent, such as an ammo- 
niacal solution of ferrous tartrate (Stokes' fluid), ammonium sulphide, 
or cuprous salts. 

Under normal conditions the amount of oxyhemoglobin is fairly 
constant, but varies somewhat in different countries, in accordance 
with the habits of the people. As a result of sixty-one estimations, 
Leichtenstern l found 14.16 per cent, as the average in healthy men, 
13.10 per cent, in women, and in old age about 95 to 115 per cent, 
of the normal. Among the inhabitants of the large cities of the 
United States such excellent results are obtained only exceptionally, 
and in my experience it is rare to find more than 13.01 per cent. As 
a general rule, amounts varying between 10.96 and 12.33 per cent, are 
observed. This difference is undoubtedly owing to the fact that the 
average German spends much more of his time outside the city- 
limits than the average American. Larger amounts are thus also 
found among the French and the English. 

While the ingestion of large amounts of water does not cause 
a dilution of the blood and a diminution in the amount of oxyhe- 
moglobin, an increase occurs upon the withdrawal of liquids. Fat 
persons show a smaller amount of oxyhemoglobin than corresponds 
to their age. 

A great diminution in the amount of oxyhemoglobin may be 
encountered under pathological conditions, and especially in chlorosis, 
while a relative increase is not infrequently met with in diabetes 



Fig. 3. 
Bed Orange Yellow Green 



Cyan-blue 



a B C 

±0 50 

llllllllll ' 



I I I I I 1 1 II 1 I I I I ill I I i ll |l| 

llllllllll llllllllll 



Eb F 

70 80 90 100 11.0 

Mllililliillllilllllillllll 



Spectrum of oxyhemoglobin, (v. Jaksch.) 

mellitus, owing to the excretion of abnormally large quantities of 
water. In nephritis with pronounced oedema it falls considerably 
below the normal. 

In a series of observations Quincke 2 found the following amounts 
in the diseases indicated : 



1 Leichtenstern, Unters. iiber d. Hsemoglohingehaltd. Blutes im gesunden u. kranken 
Zustande, Leipzig, 1878. 

2 Quincke, "Zur Pathologie d. Blutes," Deutsch. Arch. f. klin. Med., vols. xxv. and 
xxvii. 



CHEMICAL EXAMINATION OF THE BL 



Angina pectoris 
Cerebral apoplexy 
Scurvy .... 
EEepat^C cirrhosis 

Chlorosis . . . 
Splenic leukaemia 
Nephritis . . . 
Diabetes ■ . . 
Typhoid fever . 
Recurrens . . . 
Meningitis . . 
Pyaemia .... 
Phosphorus poisoning 



14 

14 

II 

10, 

5.32-9 

5. 

8.5-10. 

14.4-1.'). 

12.7-14. 

14. 

15, 

11 

14. 



4 per cent. 

1 

t) " 

1 " 

92 " 

8 " 
7 " 

9 " 
6 " 
4 " 
" 
,3 " 



Fleischl • 

107.0 

L04.9 

108.6 

75.1 

39.5-73.9 

43.1 

63.2 79.6 

107.1-118.3 

94.4-108.6 

107.0 

111.6 

84.0 

110.8 



In an analysis of 63 cases of chlorosis observed at the Johns 
Hopkins Hospital, an average amount of 5.68 per cent. (42.3, 
Fleischl), with a minimum of 2.35 per cent. (17.5), was observed. 
Similar results were obtained by the writer in an analysis of 31 
eases. The average amount was 6.46 per cent. (42.8, Fleischl), and 
the lowest 2.46 per cent. (18, Fleischl). Chlorosis thus occupies the 
foremost position among the various pathological conditions associated 
with oligochromasia. 

Very low figures are also seen in cases of pernicious anaemia and 
leukaemia, in which 2.68 per cent. (20, Fleischl) and 4.36 per cent. 
(32.5), respectively, have been obtained. 

While in typhoid fever the amount of oxyhemoglobin is always 
reduced, according to Osier, and usually in a greater relative pro- 
portion than the number of the red corpuscles, the most severe 
grades of anaemia may here be encountered during convalescence, 
when the amount of oxyhemoglobin may fall as low as 2.68 per 
cent. (20, Fleischl). 

In the early stages of carcinoma of the stomach the cachexia is 
not well pronounced, and Schiile states that in his analysis of 198 
cases it occurred in only 30 per cent. This agrees entirely with my 
experience, and I have repeatedly found amounts of haemoglobin 
exceeding 60 per cent. Later in the disease a most pronounced 
oligochromaemia is, however, invariably encountered. At this 
place I wish to insist upon the importance of systematically re- 
peated examinations of the blood in all cases of suspected car- 
cinoma of the stomach. A steady decline from week to week, 
taken in conjunction with other symptoms, and occurring in 
patients who have passed the fourth decade, is certainly very 
suspicious. 

A notable diminution in the amount of haemoglobin is further 
observed in tuberculosis, syphilis, chronic lead and mercurial poison- 
ing, chronic nephritis, chronic enteritis, etc. According to Justus, 2 
a marked fall in the haemoglobin occurs a few hours after mercurial 

1 See estimation of haemoglobin with Fleischl' s hsemometer, page 32. 

2 Justus, Virchow's Archiv, vol. cxl. p. 1. 



32 THE BLOOD. 

inunction in syphilis, while this is not observed in other diseases. 
His examinations were made in one hundred cases. Cabot and 
Mertens, 1 who repeated the work of Justus, arrived at similar results. 
In seven cases of syphilis they noted a drop of from 10 to 35 per 
cent., while in other diseases negative results were obtained, with 
the exception of one case of chlorosis, in which the hemoglobin fell 
13 per cent. 

As the oxvhemoglobin is contained in the bodies of the red cor- 
puscles, it might be inferred that the amount of haemoglobin will 
directly depend upon the number of the corpuscles, so that the degree 
of an anaemia could be determined by an enumeration of the red 
corpuscles as well as by a direct estimation of the amount of oxy- 
hemoglobin. 

AThile this rule generally holds good, there are numerous excep- 
tions which go to show that a diminution in the amount of oxyhe- 
moglobin, viz., an oligochromamia, is not necessarily accompanied by 
a corresponding diminution in the number of the red corpuscles — 
. an oUgocythcemia. In chlorosis, for example, the red corpuscles 
may be present in normal numbers, while the amount of oxyhemo- 
globin is greatly diminished. Here, it is true, a well-defined oligo- 
cythemia simultaneously occurs in all severe cases, but even then 
the oligochromemia exceeds the oligocythemia. Conversely, in 
pernicious anemia the oligocythemia, while accompanied by an 
oligochromemia, quite constantly exceeds the latter. 

It is thus clear that definite inferences regarding the amount of 
hemoglobin cannot be drawn from an enumeration of the red cor- 
puscles, and vice versa. 

^Tule it is generally possible to form a fairly clear idea of the 
degree of anemia by inspection — i. e., by noting the " color n of 
the patient — it is a well-known fact that not every pale face denotes 
an anemic condition. Whenever special accuracy in examination or 
results for comparison are desired, recourse should hence be had to 
instruments especially devised for the purpose of determining the 
amount of hemoglobin, known as hemoglobinometers or hemom- 
eters. Of these instruments, that devised by Fleisehl is undoubtedly 
the most convenient and has largely replaced those of Gowers, 
Malassez. and Hayem. 

Estimation of Haemoglobin with Fleischi's Haemometer. 2 — The prin- 
ciple of the method depends upon comparison of the color of the 
blood, diluted with water, with that of a glass wedge stained with 
the golden purple of Cassius or a similar pigment. 

The instrument (Fig. 4) consists of the glass wedge a, to which 

1 Cabot and Mertens. Boston Med. and Surg. Jour.. 1599. Xo. 14. 

- ttlieb. Wien. med. Blatt.. 1556. pp. 505 and 537. Laker. Wien. med. Woch., 

-- vol. xxsvi. Kiseh, Zeit. f. klin. Med.. 1887, vol. xii. Stierlin. Deutseh. Arch. 
f. klin. Med., 1559. vol. xlv. Beinert. Die Z'ahluns d. Blutkorperehen. etc.. Leip- 
sic, 1591. 



CHEMICAL EXAMINATION OF THE BLOOD. 



33 



a scale, b } is attached, ranging from to 120, being placed at 
the thinnest, 120 at the thickest portion of the wedge. By 
means of a rack and pinion this may be made to slide from 
side to side beneath a platform corresponding to the stage of the 
microscope. In the centre of the platform there is a circular 
opening into which artificial light (daylight is not permissible) is 
projected from a circular plate of plaster of Paris, mounted beneath, 
in the position of the mirror of the microscope. Into the circular 
opening a metallic tube, 1.5 cm. in height, closed at the bottom with 

Fig. 4. 




v. Fleischl's hsemometer. 



a plate of glass, and divided into two equal compartments by a 
metal partition, is fixed. One compartment receives the light 
through the glass wedge — the red chamber ; the other, directly from 
the plaster-of- Paris reflector — the white chamber. 

Capillary pipettes accompany the instrument, and are of such a 
capacity that, if the blood of a perfectly normal individual is used, 
the mixture of blood and water placed in the compartment receiv- 
ing light directly from the white plate corresponds in color to that 
derived from the colored wedge at the mark 100. The two com- 
partments are partially filled with water, when the required amount 
of blood is obtained by placing one end of a capillary pipette in 
contact with a drop of blood obtained from the tip of a finger that 



zee zz-::-i- 

has been carefully cleansed with water, alcohol, and finally with 
ether. The pipette is immersed in the white chamber and rotated 
between two lingers, when the water will dissolve the haemoglobin 
from the corpuscles. Any trace of blood remaining in the pipette is 
carefully washed out with water, an ordinary medicine-dropper being 
used for the purpose. By means of the dropper the two compart- 
ments are then completely filled with water until a convex meniscus 
is obtained over the two chambers. A slip of paper is placed over 
the visible portion of the scale on the surface of the platform, im- 
mediately behind the well c, and the glass wedge so adjusted by 
means of the screw that the color in the two chambers shall be the 
same. The number facing the notch in the scale-aperture of the 
platform will then indicate the percentage of haemoglobin, that of 
a healthy individual corresponding to 100. 

As the normal amount of haemoglobin in 100 grammes of blood 
is a little less than 14 grammes, the number 100 on the scale of 
Fleischl's instrument corresponding to 13.7 per cent., the percentage 
in a given specimen may be calculated according to the equation : 
100 : 13.7 : :p:x 7 and x = 0.137 p, where p represents the reading 
on the scale and * the corresponding amount of haemoglobin in 100 

According to Dehio, certain errors are incurred in the estimation 
of haemoglobin by means of Fleischl's haemometer, which become the 
more marked the smaller the percentage. These may be partially 
obviated, however, and more accurate results obtained, if the instru- 
ment is previously tested with a solution of blood the color of 
which coincides accurately with that of the wedge at the mark 100. 
To this end, the standard solution is diluted with from 10 to 90 
volumes of water, and any difference that may exist in the readings 
of the instrument, as compared with the known percentages, noted. 

^lirscher, 1 a few years ago, modified v. Fleischl's instrument in 
such a manner that nearly accurate results can be obtained. The 
instrument, how^ is -rill too costly for general use, and its descrip- 
tion is therefore omitted at this place. It mav be procured from 
C. Reiebert. in Vienna. 

I: the number of red corpuscles is known, the amount of haemo- 
globin contained in each, "la valeur globulaire w of Leprae, can be 
readily determined, and is a point of considerable importance in 
differential diagnosis. This deteraaination is a simple matter, as it 
is only necessary to divide the percentage of haemoglobin by that of 
the red corpuscles. Supposing the amount of haemoglobin to have 
been 50 per cent., and the number of red corpuscles 4,000,000 per 
cubic millimeter—*, e., 80 per cent, of the normal (5,000,000)— the 
color index would be 50 divided by SO, or 0.62. 

Under strictly normal conditions the color index is equivalent 
1 Miescher, CoraespbL f- Sehweiz. Aeizire. 1583* Xo. 23. 



CHEMICAL EXAMINATION OF THE BLOOD. 



35 



to 1. Lower values are especially seen in chlorosis, in which it may 
diminish to 0.3 and even lower, but are also common in the secondary 
anaemias. Higher values, on the other hand, are practically only 
observed in pernicious anaemia, and are hence always suspicions. 

Estimation of Haemoglobin with Gowers' Haemoglobinometer. — 
Gowers' hsemoglobinometer is less costly than that of Fleischl, 
and yields results which compare favorably with those obtained with 
that instrument The apparatus (Fig. 5) consists of a closed tube 

Fig. 5. 






Gower's hsemoglobinometer. 

(D), containing a solution of picrocarmin-glycerin, the color of 
which corresponds to a 1 per cent, solution of normal blood ; a simi- 
lar tube (C), about 11 cm. in height, provided with an ascending 
scale of 134 divisions, each corresponding to 20 cbmm.; a capillary 
pipette (B), marked at 20 cbmm.; a guarded lancet (F) ; a drop- 
ping-bottle with rubber top (A), and a small stand (E). 

In order to estimate the relative amount of hemoglobin in a given 
case, the tip of a finger, or the lobe of the ear, is freely punctured, 
after having been cleansed as described above, and the pipette filled 
with blood to the 20 cbmm. mark. Any trace of blood that may 
adhere to the outer surface of the pipette is carefully wiped off; the 
contents are mixed at once with a few drops of distilled water, 
previously placed in the graduated tube. In order to make the 
possible error incurred as small as possible, care should be had 
to remove completely every trace of blood from the interior of 
the pipette by refilling it with distilled water and blowing the 
contents into the graduated tube. The two tubes are then held 
side by side, directly against the light or against a sheet of white 
paper, when water is added drop by drop until the shade of color 



36 



THE BLOOD. 



is the same in the two. The division on the scale ultimately 
reached will express the relative percentage of haemoglobin. 

The method of estimating the amount of haemoglobin from the 
specific gravity of the blood has been described on page 11. 

Estimation of Blood-iron with Jolles' Ferrometer. — The idea of esti- 
mating the haemoglobin from the blood-iron, as suggested by Jolles, 
has unfortunately not proved practical, as constant relations do not 
exist between the two bodies. This is owing to the fact that only a 
portion of the iron occurs in the form of haemoglobin. His method 
of estimating the total amount of iron in the blood deserves consid- 
eration, nevertheless, as it may prove of practical value in clinical 
work. 

The principle of the method is the following : a small amount 
of blood is incinerated, and the remaining red oxide of iron brought 

Fig. 6. 




Jolles' ferronieter. 



into solution with a little monacid potassium sulphate. In this so- 
lution the iron is then estimated colorimetrically by means of a spe- 
cial apparatus — the ferrometer. As will be seen from the accom- 
panying illustration (Fig. 6), this consists of two glass tubes, C and 
C, which are of the same diameter throughout, and closed at the 
bottom with small glass plates, held in position by means of screws, 
as in the polarimetric tubes. Tube C is of 15 c.c. capacity, while 
tube C is a little longer and holds about 16 c.c. Both are gradu- 
ated in half cubic centimeters. Tube C is provided with an over- 



CHEMICAL EXAMINATION OF THE BLOOD. 



37 



flow tube near the bottom, 
into the perforated metal] 
ing, so as to exclude lig 
plaster-of-Paris reflector, 
and fi?. Tube ( ' receiv 
blood, and is closed with 
( " is placed the iron solut 
to flow a way through the 
color in the two tubes is 



which carries a stopcock. Both are fitted 

ic plate D, and are surrounded by a cas- 
lt from the sides. Below the plate is a 
which can be turned with the screws K 
es the iron solution, obtained from the 
an accurately lit ting glass disk, while in 
ion used for comparison. This is allowed 
overflow tube (//) drop by drop until the 
the same. But as the color in C", owing 



Fig. 




to the meniscus which is formed, would be less sharply defined than 
in C, the tube C is furnished with a cylindrical float of aluminum, 
which is closed above and below with glass disks. This float dis- 
lodges about 1 c.c. of fluid, and it is for this reason that tube C is 
a little longer than tube C. 

A capillary pipette and the necessary additional apparatus, as well 
as reagents, accompany the instrument, which is made by Reichert, 
of Vienna. 

Method. — In order to procure the necessary amount of blood, 
viz., 0.05 c.c, which is obtained by simple puncture of a finger or the 



38 THE BLOOD. 

ear, Jolles recommends that the capillary tube be first filled beyond 
the mark, and to close the pinchcock on the rubber tube at once. 
The excess of blood is then allowed to Aoav from the tube, and the 
tip is carefully wiped with filter-paper. The 0.05 c.c. is placed in 
a platinum crucible, any traces that may remain adherent to the 
tube being washed out with a little distilled water. 1 

The blood is now evaporated to dryness over a plate of asbestos, 
at first with a small flame. The crucible is then placed on a pipe- 
stem triangle, and the residue carefully incinerated. One of the 
accompanying powders, containing 0.1 gramme of monacid potassium 
sulphate is now added. The mixture is cautiously heated with 
a small flame imtil the powder begins to liquefy, when stronger 
heat is applied and the mass congeals. This step is completed in 
one or two minutes. On cooling, the material is washed into the 
cylinder C, through a small funnel with the aid of a little hot dis- 
tilled water, and diluted to the mark 10. The tube O is charged 
with 1 c.c. of the comparison-solution, and likewise filled to the 
mark 10 with hot distilled water. This solution contains 0.0005 
gramme of iron and 0.1 gramme of monacid potassium sulphate, in 
every cubic centimeter. 

To each cylinder are then added 1 c.c. of hydrochloric acid (1 : 3) 
and 4 c.c. of a solution of ammonium sulphocyanide (7.5 grammes pro 
liter). The tube C is now closed with the glass disk, care being 
taken to exclude bubbles of air, when the mixture is thoroughly 
shaken and the tube fixed in the metallic plate. Tube C is likewise 
closed with a glass disk ; its contents are well agitated, the disk is 
removed and replaced by the carefully dried float. This should be 
placed upon the fluid slowly and with a screwing motion, so as to 
exclude bubbles of air. After this tube has also been placed in 
position the reflector is adjusted, and so much of the comparison- 
solution allowed to escape as to make the color in the two tubes the 
same. O is then removed from its base and the reading taken. In 
the table below, the corresponding amount of iron in 1000 c.c. of 
blood may be directly read off. Should it be desired to obtain the 
percentage by weight, the specific gravity of the blood should first be 
ascertained, and the necessary calculation made according to the 

equation D : V: : 100 : x, and x= — ~ — , in which D represents 

the specific gravity, and V the percentage by volume. The resulting 
differences, however, are so small that they may be neglected, and 
for practical purposes it will be sufficient to assume a specific gravity 
of 1.050, and to read off the percentage by weight directly. To 
this end, the second column in the table has been constructed. 

1 The pipette should always he cleansed immediately after use. It is hest washed 
out with dilute sulphuric acid 1 10 per cent. I, then with dilute sodium hydrate solution 
(5 per cent.), and finally with alcohol and ether. 



CHEMICAL EXAMINATION OF THE BLOOD. 39 

Table to ascertain the Ajmount of Ikon in L000 c.c. ©p 
Blood, and the Percentage by Weight, prom the 
Number of c.c. of the Comparisonhsolution used. 



Cc. of comparison- 


Iron in 1000 C.C. 


Iron-percentage 


solutiun used. 


of blood. 


by weight. 


15.0 


1.000 


0.0952 


14.5 


0.967 


0.092(1 


14.0 


0.933 


0.0889 


13.5 


0.900 


0.0857 


13.0 


0.867 


0.0825 


12.5 


0.833 


0.0794 


12.0 


0.800 


0.0762 


11.5 


(•.767 


0.0730 


11.0 


0.733 


0.0698 


10.5 


0.700 


0666 


10.0 


0.667 


0.0635 


9.5 


0.633 


0.0603 


9.0 


0.600 


0.0571 


8.5 


0.567 


0.0540 


8.0 


0.533 


0.0508 


7.5 


0.500 


0.0475 


7.0 


0.467 


0.0444 


6.5 


0.433 


0.0412 


6.0 


0.400 


0.0381 


5.5 


0.366 


0.0349 


5.0 


0.333 


0.0317 


4.5 


0.300 


0.0285 


4.0 


0.266 


0.0254 


3.5 


0.233 


0.0222 


3.0 


0.200 


0.0191 


2.5 


0.166 


0.0158 


2.0 


0.133 


0.0127 


1.5 


0.100 


0.0095 


1.0 


0.067 


0.0063 



Some of the results which have thus far been obtained are given 
in the following table : 

Iron in 100 c.c. of blood 
by weight. 

Normal 0.0413-0.0559 

Chlorosis 0.0203 

Diabetes (severe) 0.0292 

Carcinoma of uterus after hemorrhage 0.0152 

Secondary anaemia 0.0177 

Jellineck, who has made a careful comparative study of the blood 
with Jolles* instrument and v. Fleischl's hsemometer, arrived at some 
very interesting conclusions. In diabetes he thus found that the 
amount of iron steadily diminishes, although the haemoglobinometer 
gives higher readings. In a case of malaria the iron remained con- 
stant before and after the chill, while with v. Fleischl's instrument 
variable results were obtained. In two cases of leucocytosis the 
ferrometer gave low readings, and in eight eases of secondary anaemia 
the hsemometer gave much higher values than the ferrometer. 

In a series of cases Jolles also examined into the presence of iron 
in the serum, by centrifugating a given volume of blood mixed with 



40 THE BLOOD. 

an 0.8 per cent, salt solution, and found that in health the serum 
contains no iron. In three cases of chlorosis, in one case of leukae- 
mia, in one of neoplasm, and one of interstitial nephritis, negative 
results were likewise reached. In two cases of severe diabetes, on 
the other hand, notable quantities were found. 

More recently Jolles has modified his ferrometer in such a manner 
that the comparison of the sulphocyanide solution, obtained from the 
blood, is made with the colored wedge of Fleischl's ha?mometer. 
The new instrument he terms the clinical ferrometer, and, as made 
by Reichert in Vienna, it can readily be transformed into the 
haeruometer proper. Full directions accompany the apparatus. The 
results are expressed in relative terms, the figures 100 on the scale 
corresponding to 0.0425 per cent, by weight of iron. Some of the 
results which have been obtained with this instrument are given 
below, together with the corresponding figures indicating the amount 
of haemoglobin. 

Ferrometer Hfemometer 

number. number. 

Normal 303.0 100 

Normal 92.6 105 

Normal 95.5 100 

Normal 110.0 105 

Normal 83.8 92 

Chlorosis 32.1-68.2 30-65 

Simple anaemia 33.2-74.7 15-40 

Icterus 55.0 80 

Leukaemia 40.7 32 

Leukaemia 38.6 35 

Pseudoleukemia 77.24 75-80 

Severe diabetes 78.7 30 

Severe diabetes 91.4 35-40 

Parenchymatous nephritis 51.7 50 

These figures at once illustrate the lack of relation which exists 
between the amotmt of haemoglobin and that of the blood-iron as a 
whole. 

Litebatvre. — A. Jolles. " Ferrometer." Deutsch. med. Woch., 1897. No. 10; Ibid.. 
1S9S. No. 7. Hladik. "rntersuchungen iiber d. Eiseugehalt d. Blutes gesunder Men- 
schen," Wien. klin. Woch.. 1898, No. 4. S. Jellineck. " Feber Farbekraft und Eisen- 
gehalt d. Blutes.'* Ibid.. Nos. 33. 34. A. Jolles. " Vereinfaehtes klin. Ferrometer," 
Berllin klin. Woch.. 1S99. No. 44. p. 965. 

Hsemoglobinsemia. — The term ha?moglobina?mia has been applied 
to a condition in which the haemoglobin is dissolved out from the red 
corpuscles, and, appearing in the plasma as such, leads at first to a 
very decided choluria and in extreme cases to haenioglobinuria. 

Various poisons, such as potassium chlorate, carbolic acid, pyro- 
gallie acid, naphtol, arsenic, sulphide of antimony, hydrochloric 
acid, sulphuric acid, antifebrin, antipyrin, phenacetin, sulphonyl, 
tincture of iodine, when given hypodermically, or even internally in 
snfficientlv large doses, will call forth a haemoglobinaeinia which is 
followed by hemoglobinuria. 




CHEMICAL EXAMINATION OF THE BLOOD. 41 

Fresh morels also contain a poison which is capable of producing 
an intense hemoglobinuria, and which may be extracted with hot 
water. 

In acute and chronic infectious diseases of a severe type, such as 
scarlatina, typhoid fever, intermittent fever, icterus gravis, syphilis, 
as also in diseases depending upon a hemorrhagic diathesis, such as 
variola hemorrhagica, scurvy, as also following insolation, extensive 
burns, and frostbite, hemoglobinemia, leading to hemoglobinuria, is 
not infrequently observed. 

An epidemic hemoglobinuria of the newly born and a paroxysmal 
or intermittent hemoglobinuria, both of unknown origin, have like- 
wise been described. 

In a case of Raynaud's disease which I had occasion to observe in 
the clinic of Dr. H. M. Thomas, at the Johns Hopkins Hospital, 
hemoglobinuria at times followed epileptiform seizures. 

Hemoglobinemia followed by hemoglobinuria is finally observed 
after transfusion of the blood of one mammal into the circulation of 
another. 

In some cases, and particularly in those following poisoning with 
chlorates, etc., the hemoglobinemia ultimately leads to a well-pro- 
nouneed methemoglobinemia (see below r ). 

A hemoglobinemia, aside from the urinary examination, may be 
readily recognized by a spectroscopic examination of the serum, when 
the two bands of absorption of oxyhemoglobin will be observed. 

A very simple method which may be employed for the same pur- 
pose is the following : a small amount of blood is drawn from the 
patient by means of cupping-glasses and immediately placed on ice, 
where it is allowed to remain for from twenty to twenty-four hours. 
At the expiration of this time the clot will have shrunk, floating, if 
the blood is normal, in the clear, straw-colored serum, while a 
beautiful ruby-red color is obtained in cases of hemoglobinemia. 
If some of this serum is then heated to a temperature of from 70° 
to 80° C, the coagulum in the presence of hemoglobin will present 
a more or less deep-brown color. 

Literature.— Ponfick, Vcrhandl. d. Cong. f. inn. Med., 1883, vol. ii. p. 205. 

Stadelmann, Arch. f. exp. Path. u. Pharmakol., 1882, vol. xv. p. 337, and 1884, 

vol. xvi. pp. 118 and 221. Afanassiew, Zeit. f. klin. Med., 1883, vol. vi. p. 281. 
v. Jaksch, Verhandl. d. Cong. f. inn. Med., 1891, vol. x. p. 353. 

Carbon Monoxide Haemoglobin. — In cases of coal-gas poisoning 
the blood, both of arteries and veins, presents a bright cherry-red 
color, owing to the presence of carbon monoxide hemoglobin. 

Such blood, when properly diluted, like oxyhemoglobin, shows two 
bands of absorption between I) and E (Fig. 8), which arc nearer the 
violet end of the spectrum, however, and may readily be distinguished 
from those referable to oxyhemoglobin by the addition of a reducing 
agent. This will not affect the spectrum of carbon monoxide hemo- 



42 



THE BLOOD. 



globin, while that of oxyhemoglobin is transformed into the spectrmn 
of reduced haemoglobin. 

For medico-legal purposes a number of additional tests have been 
devised, among which that suggested by Hoppe-Seyler is one of the 
simplest and at the same time most reliable. The blood is treated 
with double its volume of a solution of sodium hvdrate (sp.gr. 

Fig : 



Bed 


Orange 


YeOam 








Green Cyan-blue 


d 


1 a B ( 

ml iiihni 


: d 

a 60 
imlmilmi ii 


Eb F 

70 SO 9D 100 UD 

II 1 I 1 1 1 1 II II 1 1 1 1 II 1 1 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i 1 1 i 1 l 














i 


I 


1 



tram of carbon m one xk . . .'_. ~ 7 _■_!>.:-: 



1.3). Normal blood is thus changed into a dirty-brownish m ;-- . 
which exhibits a trace of green when spread upon a porcelain plate, 
while carbon monoxide blood yields a beautiful red under the same 
conditions. 

Nitric Oxide Haemoglobin. — The blood in cases of poisoning 
with nitric oxide, owing to the presence of nitric oxide haemoglobin, 
yields a spectrum which is similar to that of carbon monoxide haemo- 
globin ; the bands, however, are less sharply defined and paler than 
those of the latter, and, like these, do not disapj>ear on the addition 
of a reducing substance. 

Hydrogen Sulphide Haemoglobin (Methaemoglobin Sulphide). 
— In cases of poisoning with hydrogen sulphide no definite cha:_r- 
can be discovered in the blood upon spectroscopic examination, 
although Hoppe-Seyler lias shown that haemoglobin may enter into 
combination with this gas. It is stated, however, that in such cases 
the blood becomes dark and of a dull-greenish tint, and that the 
distinction between arterial and venous blood is lost. 

Carbon Dioxide Haemoglobin. — With carbon dioxide, as men- 
tioned above, haemoglobin is also thought to enter into combination, 
the spectrum being similar to that of reduced haemoglobin. The 
latter, in fact, is formed artificially when carbon dioxide is pass 
through a solution of oyxhaeinoglobin. If this pi sees is earned 
further, the haemoglobin is decomposed and a precipitate of globulin 
thrown down : an absorption-band is then obtained which is similar 
to that resulting when haeniocrlobin is decomposed with acids (see be- 
low). The question has hence arisen whether the so-called carbon 
dioxide haemoglobin spectrum is not in reality referable to carbon 
monoxide ha^mochromogen, the haeinochromiogen, according to Hoppe- 
Sevler, being the colored portion of the haemoglobin and its com- 
pounds with gases. 



CHEMICAL EXAMINATION OF THE BLOOD. 



43 



Of the blood -el uin lies occurring in cases of poisoning with hydro- 
cyanic acid and acetylene, but little is known, and the reader is 
referred to works on toxicology for their consideration. 

Haematin. — If haemoglobin in aqueous solution is heated to a 
temperature of from (J0° to 70° C, it is decomposed into an albu- 
minous body, belonging to the class of globulins, and haematin. The 
same result also is reached by treating the aqueous solution with 
acids, alkalies, or the salts of various heavy metals. 

Haematin is an amorphous, blackish-brown or bluish-black sub- 
stance which is frequently encountered in old transudates, in the 
stools after hemorrhages, and after meals consisting largely of red 
meats. It is said to occur in the urine in cases of poisoning with 
arsenic, and in the blood of animals poisoned with nitrobenzol its 
presence can likewise be demonstrated Avith the spectroscope. 



Fig. 9. 



Red Orange 

A 



Yellow 



Green 



Pnan-blue 



B C D Eb 

10 50 60 70 80 

I t | I 1 I I M I t [l I I I I I I I I I I I I I 1.1 I I I I I I I I 1 I I I I 1 I I | I I I I I I 1 



100 110 

llllllllll 1 



Spectrum of hcematin in alkaline solution, (v. Jaksch.) 

In acid solutions it shows a well-defined spectral band between 
Cand I) (Fig. 11). Between Dand Fa second band is seen, which 
is much wider but less sharply defined than the first, and may be 
resolved into two bands by dilution, one between b and F, near F, 
and another between D and F, near E ; a faint fourth band may 
also be seen between I) and. F, near D. As a rule only the two 
bands between D and F are visible. 



Fig. 10. 



Red Orange 



Yellow 



Green 



Chian-hhir 



A 



D 
60 

Innl,, 



Eb 

70 80 30 

I i i mIiijiImmImm I im,! 



JunL 



Spectrum of reduced hsematin. (v. Jaksch.) 

Iii alkaline solutions it shows but one broad band, the greater 
portion of which lies between C and D, extending slightly beyond 
D (Fig. 9). 

If an alkaline solution of haematin is treated with a reducing 
substance, reduced hsematin results, which gives rise to two bands 
of absorption between D and E (Fig. 10). 



44 THE BLOOD. 

Haemin. — Bheinatin readily combines with one molecule of hv- 

li shloric acid to form hsemin. This substance crystallizes in light- 
er dark-brown rhombic plates or columns, which are highlv charac- 
teristic (Plate I.. 1 i. They bear the name of their discoverer. 
Teichmann. The size of these crystals varies with the manner in 
which they are produced, the largest specimens being met with 
when the glacial acetic acid | see below > is allowed to evaporate as 
slowly as possible. Specimens measuring from 15 >± to 18 a in 
length may then be seen. Smaller crystals will be present at the 
same time, occurring either singly or hi the form of stars, rosettes, 
and crosses. 

As these crystals may be obtained from mere traces of blood, their 
formation must be regarded as conclusive evidence in medico-legal 
examinations. Lewin and Rosenstein have pointed out. however, 
that under certain conditions a negative result may be reached, even 
if the coloring-matter is derived from the blood. This is the case 
especially when the haemoglobin has been transform el into hsemo- 
chromogen or hsematoporphyrin. or when substances have been mixed 
with the blood which are either capable of altering its general com- 
position or which, through their mere presence, interfere with the 
reaction. Such substances are certain salts of iron (rnst), lead, mer- 
cury, and silver : iurther. lime, animal charcoal, and sand, when 
intimately mixed with the blood. In medico-legal cases a spectro- 
scopic examination should hence also be made whenever the haemin 
reaction is not obtained. 

Method. — A small drop of normal salt-solution is carefully 
evaporated on a slide, when a few particles of the suspected material, 
powdered or teased as hnely as possible, are placed upon the delicate 
layer of crystallized salt. The preparation is covered with a cover- 
glass, and glacial acetic acid allowed to just fill the space between the 
two glasses. The specimen is then carefully heated ('three-quarters 
: : : ne minute) until bubbles oi gas begin to form beneath the cover. 
'W mile evaporation is being continued glacial acetic acid is further 
added, drop by drop from the edge of the slip, until a faint reddish- 
brown tint appears. As soon as this point is reached, the last traces 
of the acid are allowed to evaporate, the specimen being held at a 
greater distance from the flame. A drop of glycerin is finally added, 
when the preparation mav be examined under the microscope, atten- 
tion being directed especially to reddish-brown streaks or specks. 
which, in the presence of blood, can usually be made out with the 
naked eye. 

Methsemoglobin. — Methsemoglobin is a pigment closely related to 
r~mamioglobin. and is frequently encountered in hemorrhagic transu- 
dates, cvstic fluids, and in the urine in cases of hematuria and hemo- 
globinuria. In the circulating: blood methsemoglobin is found after 
the ingestion of large quantities of potassium chlorate, notably so in 



PLATE 



FIG. 1. 



ib 



Crystals of Hsemin. (Hicjhly magnified. 



FIG. 2. 




Crystals of Hsematoiclin from an Acholic Stool, 
(v. Jakseh.) 



CHEMICAL EXAMINATION OF THE BLOOD. 



45 



children, as also alter the inhalation of nitrite of amy], the use of 
kairin. thallin, hydrochinon, pyrocatechin, iodine, bromine, turpen- 
tine, ether, perosmic acid, permanganate of potassium, and antil'cbrin 
(see Haemoglobinsemia). 



Fig. 11. 



Red Orange 



Yclloic 



Green 



Cyan-Uue 



A a B C D 

40 60 60 

ll'lllll lllllllll 







Eb 

70 80 

iil i ii i jnnlm i l 



no 



■ 



Spectrum of methaemoglobin in acid and neutral solutions, (v. Jaksch.) 

The spectrum of an aqueous or slightly acidified solution of methae- 
moglobin (Fig. 11) closely resembles that of an acid solution of 
haematin, but differs from this in the ease with which it is trans- 
formed into that of haemoglobin when an alkali and a reducing 
substance are added. The spectrum of haematin under the same 
conditions is transformed into that of an alkaline solution of haemo- 
chromogen. In alkaline solutions, on the other hand, two bands 
of absorption are observed, which are similar to those of oxy- 
hemoglobin, but differ from these in the fact that the band nearer 
£, ,3, is more pronounced than the one at D, a. A third, but 
very faint, band may further be observed between C and D, 
near D. 

Haematoidin. — Small amorphous particles of an orange or ruby- 
red color, or crystals belonging to the rhombic system (Plate I., 
Fig. 2), occurring either singly or in groups, are frequently met 
with in the sputum, the urine, and the feces, as well as in old 
extravasations of blood. They were discovered by Virchow, who 
applied the term haematoidin to this particular pigment, the 
haemic origin of which is undoubted. It is supposedly identical 
with bilirubin. 



Fig. 12. 



Red Orange Yellow 



Green 



Cyan-blue 




Spectrum of hsematoporphyrin in 



solution. 



Haematoporphyrin. — Ha?matoporphyrin is likewise a derivative 
of haematin, and, according to Xencki and Sieber, isomeric with 



46 



THE BLOOD. 



bilirubin. In dilute solution with sodium carbonate it shows four 
bands of absorption, one between C and D, a second one, broader 
than the first, about D, especially marked between D and E, a third 
one, not so broad and less sharply defined between D and E, and a 
fourth one, broad and dark, between b and E (Fig. 12). 

The clinical significance of this body, which, also appears in the 
urine, as well as the causes giving rise to its formation, are as yet 
unknown (see Haematoporphyrinuria). ■ It has been found post 
mortem in the blood, in a case of sulphonal poisoning, by A. E. 
Taylor and J. Sailer. 1 

AYhile it is usually possible, as pointed out above, to recognize 
definitely the presence of blood by the hsemin test, recourse should 
always be had to a spectroscopic examination whenever the exact 
nature of the pigment under consideration is to be determined. 

The Spectroscope. — The spectroscope (Fig. 13) essentially con- 
sists of a tube (A), provided with a slit at its distal end, which may 

Fig. 13. 




The spectroscope. (Netjbauek ) 

be narrowed or widened, and a collecting-lens at its proximal end. 
Through the latter, rays of sunlight or of artificial light are thrown 
upon a prism (P), where they are decomposed into a colored spec- 
trum, which is viewed through an astronomical telescope (B). 

1 A. E. Tavlor and J. Sailer, Contrib. from the William Pepper Laboratory, Phila., 
1900, p. 120.' 



T1IK 1R0TKIDS OF THE BLOOD, 



17 



Through a third tube (C) a fine scale, illuminated by artificial light, 
is reflected by the prism to the eye of the observer, appearing im- 
mediately above the colored spectrum. The left of this is red, 
passing into yellow, this into green, then into blue, indigo, and finally 
into violet, which occupies the right end. These colors, however, 
are not continuous, but are interrupted by a large number of verti- 
cally placed dark lines, named after Frauenhofer. The most marked 
of these are designated by the letters .1, a, B, C, D, E, t>, F, G> 
and //. Of these, A is found at the left end and B in the middle 
of the red portion of the spectrum, C at the boundary of the red and 
the orange, D in the yellow, E in the green, F in the blue, G in the 
indigo, and JET in the violet portion ; a is situated in the red between 

Fig. 14. 





Browning's spectroscope. (Zeiss.) 

A and B, nearer A, and b in the green between E and F, nearer 
E (see Fig. 2). 

If now r a colored medium is placed between the slit and the light, 
not all the rays of colored light reach the eye, but some become ab- 
sorbed. In the case of the blood, for example, it may thus be seen 
that a portion of the yellow and a portion of the red rays are ab- 
sorbed, a spectrum of this kind being spoken of as an absorption- 
spectrum. 

For clinical purposes various instruments, modifications of the one 
described, have been devised, among which those of Desego, of 
Heidelberg, Zeiss, of Jena (Fig. 14), and Hoffman, of Paris, as well 
as Hering's lensless spectroscope, and Henocque's instrument, are 
quite serviceable. 

THE PROTEIDS OF THE BLOOD. 

In considering the proteids of the blood from a clinical point of 
view, it is necessarv to distinguish between an increase and a dimi- 
nution in their normal amount, constituting the conditions of hyper- 
albuminosis and hypalbuminosis, respectively. As may be expected, 
the former is met with whenever water is more rapidly withdrawn 



48 THE BLOOD. 

from the system than it can be supplied, and is hence observed in 
cases of cholera, acute diarrhoea, following the use of purgatives, etc. 
This increase in the amount of proteids is only a relative increase, 
however. The occurrence of an absolute increase has not been 
satisfactorily demonstrated. An absolute hypalbuminosis, on the 
other hand, is observed following a direct loss of proteids from 
the blood, as in hemorrhage, dysentery, albuminuria of high degree, 
the formation of large collections of pus, etc. This is generallv 
associated with a relative increase in the amount of water — i. e., a 
hydrsemia — which is particularly noticeable after hemorrhages, and 
referable to a diminished secretion and excretion of water, as well 
as to a direct absorption from the tissues. 

The term hyperinosis has been applied to a condition in which the 
amount of fibrin is increased. This is said to occur in various 
inflammatory diseases, such as pneumonia, pleurisy, acute articular 
rheumatism, and erysipelas, while a diminished amount of fibrin, 
hypinosis, has been observed in malaria, nephritis, pyaemia, and per- 
nicious anaemia. 

In order to determine the amount of fibrin, 30 to 40 c.c. of blood, 
obtained by means of cupping-glasses, are placed in a previously 
weighed beaker, fitted with an India-rubber cap, through the centre 
of which passes a piece of whalebone, firmly fixed. The blood is 
defibrinated by beating with the whalebone, when the beaker with 
its contents is weighed, the difference indicating the weight of the 
blood. The beaker is then filled with water and the mixture again 
beaten. The fibrin is allowed to settle and after being washed 
with normal salt-solution filtered through a filter of known weight. 
It is further washed with normal salt solution until free from color- 
ing-matter, then boiled in alcohol to dissolve out the fat, cholesterin, 
and lecithin, dried at 110° to 120 c C, and on cooling weighed over 
sulphuric acid. 

In leukaemic blood v. Jaksch l was able to demonstrate peptones 
in considerable quantities, and especially so after death, when the 
amount progressively increased as decomposition advanced. Mat- 
thes, 2 on the other hand, could detect no true peptones, but found 
that the blood contained a deutero-albumose. In one case the serum 
contained an abundance of nucleo-albumin, derived in all probability 
from degenerated leucocytes. 

More recently album oses have also been found in a case of abscess 
of the brain associated with albumosuria. Freund 3 claims that 
peptones are found in the blood in cases of sarcoma, while in carci- 
noma they are absent. This statement, however, lacks confirmation. 

Following the injection of nuclein and spermin, moreover, albu- 

1 v. Jaksch, Zeit. f. phvsiol. Chem.. vol. xvi. p. 243. 
2 Matthes, Berlin, klin. Woch.. 1894, Xos. 23 and 24. 
3 Freund und Obermayer, Zeit. f. pkysiol. Chem.. vol. xv. p. 310. 



THE PROTEIDS OF THE BLOOD. 49 

mossemia appears to occur quite constantly both during the stage of 
hypo- as well as hyperleucocytosis. Alter injections of pilocarpin 
albumosuria is observed only in association with hyperleucocytosis. 

In order to test for albumoses, all other proteids should first he 
removed, when a positive biuret-reaction in the filtrate will indicate 
their presence (^see also Salkowski's test). 

Carbohydrates. 

Sugar. — Sugar, as indicated above, is a normal constituent of the 
blood, its quantity varying between 1 and 1.5 pro mille. Under 
pathological conditions this amount may be exceeded by far, and 
notably so in diabetes, in which Hoppe-Seyler found as much as 
9 pro mille in a given case. 

In addition to sugar, a non-fermentable reducing substance has 
been encountered in the blood, which, according to Mayer's recent 
investigations, appears to be a compound glucuronate. 1 The presence 
of jecorin in the blood still remains to be proved. 

Large quantities of a reducing substance, the greater portion of 
which consisted of sugar, have been met with by Trinkler in carci- 
noma ; it was observed at the same time that carcinoma of the inter- 
nal organs was associated with far greater amounts of sugar than 
cancerous disease of the skin and the mucous membranes. It is 
also interesting to note in this connection that an increase in the 
degree of the cachexia was not accompanied by an increase in the 
percentage of sugar. 

The results reached by Trinkler 2 apparently also bear out the 
correctness of the conclusions formed by Freund, who claimed that 
a differential diagnosis between carcinoma and sarcoma, in which 
latter condition no increase in the amount of sugar was noted, can 
always be effected upon the basis of an examination of the blood 
in this direction. 

In the following table the percentages found in the different dis- 
eases investigated are given, from which it is apparent that, next to 
carcinoma, the largest quantities of sugar are met with in the infec- 
tious diseases and the lowest figures in diseases of the kidneys : 

Average. Minimum. Maximum. 

Per cent. Per cent. Per cent. 

Carcinoma 0.1819 0.1023 3030 

Typhoid fever 0950 0.0875 1022 

Pneumonia 0943 0.0813 0.1092 

Dysentery 0.0S38 0.0796 0.0915 

Heart disease 0.0737 0.0664 0.0897 

Peritonitis 0.07^1 0.0450 0.0917 

Tuberculosis 0.0653 0450 0.0817 

Syphilis 0.0553 0.0449 0748 

Nephrit is and uraemia .... 0.0489 0.0321 0.0559 

1 P. Mayer, Zeit. f. physiol. Chem., vol. xxix. p. 59. 

2 Trinkler, Centralbl. f. d. med. Wiss., 1890, p. 498. Freund and Obermayer, loc. cit. 

4 



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__t r: : ttiz-z :■= 
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THE PROTEIDS OF THE BLOOD. 51 

and 40 cbmm. of a 6 per cent, aqueous solution of potassium 
hydrate are added. A control-tube is similarly charged with non- 
diabetic blood. The two specimens are then placed in boiling water 

and allowed to remain for from three to lour minutes, without 
shaking. At the end of this time it will be seen that the diabetic 
blood has decolorized the methylene-blue solution, which has turned 
a dirty yellowish-green or yellow, while the non-diabetic specimen 

has retained its original color. 

The quantity <)t' blood used should not exceed the amount indi- 
cate" 1, as a decolorization of the methylcne-blue also results with 
non-diabetic blood if large amounts, such as 60 cbmm., are em- 
ployed. 

The reaction is supposedly due to an increase of glucose in the 
blood, and was obtained in all of forty-throe cases of diabetes which 
were examined. It is said to be obtainable for a considerable time 
after death. Adler l found the reaction in all of nine cases of dia- 
3, while in one hundred and twentv-one non-diabetic cases nesni- 
tivo results were reached. Very curiously, it was absent in non- 
diabetic glucosurias. Adler believes the reaction to be referable to 
a diminished alkalinity of the blood. 

Glycogen. — There appears to be no doubt that glycogen normally 
occurs in the blood of various animals. Huppert 2 succeeded in 
demonstrating its presence in all animals examined, the amount 
varying between 0.114 and 1.560 grammes for 100 parts of blood. 
Czerny, 3 on the other hand, was not able to confirm these results in 
the case of healthy adults, while in sick children an examination of 
the leucocytes furnished positive results, glycogen being met with in 
chronic gastro-intestinal diseases, pneumonia, anaemia, furunculosis, 
cachectic conditions the result of tubercular disease, asphyxia, etc. 
In diabetes and leukaemia the glycogen reaction is said to be quite 
pronounced. 

Livierato, 4 who recently investigated this question with great care, 
arrived at the following conclusions : 1. Glycogen is constantly 
present in the blood of healthy individuals ; its presence, however, 
is confined to the blood-plasma. \Vhen present in increased amounts 
it also occurs in the leucocytes. 2. It is absent in cases of acute 
articular rheumatism and in inflammatory conditions of the serous 
membranes. 3. Increased amounts are found in acute croupous 
pneumonia, in typhoid fever, in phthisis, and in various exanthemata, 
etc. 4. In hepatic and cardiac diseases associated with effusion it is 
either absent or present in traces. 5. An endoglobular reaction 
only may be obtained during the second half of the ninth month of 
pregnancy and during the first four or five days of the puerperal 

1 Adler, Zeit. f. Heilk.. 1900. vol. xxi. No. 11. 

2 Huppert, Zeit. f. physiol. Chem., 1S93. vol. xviii. p. 1) \. 

3 A. Czerny. Arch. f. exp. Path. u. Pharmakol., 1893, vol. xxxi. p. 190. 

4 Livierato, Arch. f. klin. Med., vol. liii. p. 303. 



52 THE BLOOD. 

period. 6. An increase in the amount of glycogen is dependent 
upon the existence of an active local lesion, associated with fever. 
upon the formation of exudates containing peptonizable material, or 
upon the existence of a more or less pronounced hyperleucocytosis. 
A •- »rding to Kaminer. 1 it is commonly seen in puerperal fever. A 
positive reaction is obtained also in severe contusions and fractures — 
two to three days after the injury — in rapidly progressing staphylo- 
coccus and streptococcus infections, and following narcosis. 

In contradistinction to chloro-:-. pseudoleukemia, and the 
mon forms of mild sec ndary anaemia, iodophilic leucocytes are 
found only in the severer forms, such as pernicious anaemia leu- 
kaemia, etc. - 

Ehrlich explains the appearance of glycogen in the leucocytes by 
assuming that this is present in every cell as a colorless compound, 
from which the glycogen is easily split off and may then be demon- 
strated as such. 

In order to test for glyc _ - :: is )est fcc spread a drop of blood 
between two cover-glasses and place the air-dried specimens in a 
small jar containing^ few crystals of iodine. After several minutes 
the blood films assume a dark-brown color, when they are mounted 
in a drop of a saturated solution of hevulose and examined with an 
oil-immersion lens The red corpuscles are stained the color of 
iodine, while the lei: jrt - are almost colorless. All glycog-::- 
granules. whether contained in leucocytes or free in the blood, are 
stained a distinct mahogany. Ehrlich suggests that this method be 
used more extensively in the study of diabetes and other diseases. 
I: certainly furnishes far better results than staining with a solu- 
tion composed of 1 gramme of iodine and 3 grammes of potassium 
iodide in 100 grammes of a concentrated solution of mucilage. He 
also states that the same method may be very advantageously used 
in testing for glycogen in the secretions, as in gonorrhceal pus. 
tumor-cells, et 

Cellulose. — Cellulose has occasionally been found in the blood of 
tubercular patients. 

Urea. 

Urea occurs normally in the blood in traces — 0.016 to l 
cent. Larger amounts are encountered whenever, for any rea-oii. as 
in nephritis, van ~ liseases of the urinary organs, cholera Asiatica, 
cholera infantum, eclampsia, etc.. its elimination is impeded, or 
whenever, as in fever, owina to increas Jmminous decomposition, 
urea is formed in abnormally large quantities 

1 S. Kaminer. "Leukocytoseund Iodreaction imLenkoeyten," Deutsoh. med. Woch.. 
1899 p. 206: and ''Feber die jodempfindliche Substanz im Leukoeyten." Berlin. 
klin. Woch., 1899. p. 119. 

2 Ij. Hof bauer, u Feber das Torkommen jodopbiler Lenkoeyten bei Blutkrankheiten." 
Centralbl. f. inn. Med., 1900. Xo. 6. 



THE PBOTEIDS OF THE BLOOD. 53 

In this connection it is interesting to note that a smaller amount 
of urea is found in fatal cases of eclampsia than in those ending in 
recovery, an observation which has been explained by the assumption 
that in this condition the functional activity, not only of the kidneys, 
but also of the liver, is lost. 

The methods which are available for the detection of urea in the 
blood are still too complicated for clinical purposes, and the value 
of the information derived so small as hardly to warrant the labor 
involved. Hoppe-Seyler's method should be employed whenever an 
examination in this direction is deemed advisable. 1 

Uraemia. — Formerly, it was thought that the complex of symp- 
toms generally spoken of as uraemia was referable to the retention 
in the blood of urea or ammonium carbonate. This view has since 
been disproved, however, although it must be admitted that in 
uraemia an increased amount of urea is frequently noted. Other 
views, according to which uraemia is referable to an accumulation 
of potassium salts, of extractives, and especially of kreatinin, or of 
ptomams in the blood, must still be regarded as being sub judice. 
There is no reason, however, to ascribe the ursemic condition to the 
retention in the blood of one particular constituent of the urine, and 
it is not improbable that a retention of all may be responsible for 
the symptoms observed. 

Literature.— Feltz and Eitter, De l'uremie exper., Paris, 1881. Astaschewsky, 
St. Petersburg, raed. Woch., 1381, No. 27. Bouchard, Legons sur 1' autointoxication, 
Paris, 1S37. Rovigni, Eivista clinica, 1836. 

Ammonia. 

Normal venous blood, according to the researches of Winterberg, 
contains about 1 mgrm. of ammonia for each 100 c.c. In febrile 
conditions variable results are obtained, but it appears certain that 
a definite relation between the height of the fever and the amount of 
ammonia does not exist. In chronic hepatic diseases, and notably 
in cirrhosis, it is not increased. The course of acute yellow atrophy 
also is not necessarily associated w r ith an increase. Very significant 
is the observation that in ursemia following extirpation of the kid- 
neys no increase is observed. An ammoniaBmia in the sense of v. 
Jaksch can hence scarcely be said to exist. 

Literature.— Nencki. Pawlow, and Zaloski. Arch. f. exr>. Path. u. Pharmakol., 
1896, vol. xxxvii. p. 26. Winterberg, Wien. klin. Woch., 1897, p. 330. 

Uric Acid and the Xanthin-bases. 

Uric Acid. — Formerly, the presence of appreciable amounts of 
uric acid in the blood was regarded as pathognomonic of gout. But 
we now know that a lithaemic condition may occur also in other 

^ee Hoppe-Seyler. Handbuch der physiologisch- und pathologisch-chemischen 
Analyse, Vierte Auflage, p. 363. 



54 THE BLOOD. 

diseases. Traces of uric acid are indeed encountered under normal 
conditions. 

A definite lithaeruia has been observed in a variety of disorders, 
such as pneumonia, acute and chronic nephritis, chronic gastritis, 
catarrhal angina, conditions associated with an insufficient aeration 
of the blood, as in the various diseases of the heart, in pleurisy with 
exudation, emphysema when accompanied by cyanosis, the severer 
forms of anaemia, etc. v. Jaksch claims to have found uric acid in 
the blood in 88.88 per cent, of his cases of nephritis. Fever in 
itself does not appear to lead to an increased production of uric acid, 
as negative results were obtained in nine cases of typhoid fever out 
of eleven, in five cases of acute articular rheumatism out of six, etc. 
The conclusion is thus forced upon us that the diminished alkalinity 
of the blood observed in nephritis and anaemia is, to some extent at 
least, dependent upon the presence of a nitrogenous acid, while the 
diminished alkalinity of the blood observed in fevers is not referable 
to this cause. 

From a survey of the literature upon the subject it appears that 
an increased elimination of uric acid in the urine is not necessarily 
accompanied by an increase in the amount of uric acid in the blood. 
Further researches in this direction are, however, highly desirable, 
and particularly so in connection with the various forms of gastric 
disease, in which an increased elimination of uric acid, according 
to my experience, is so frequently observed. 

The assumption that acute attacks of gout are referable to an 
increased alkalinity of the blood, and a consequent increase in the 
amount of uric acid, has been disproved. 

In order to test for uric acid in the blood, the following method 
maybe employed: 100 to 300 c.c. of blood, obtained by means 
of cupping-glasses, are at once diluted with three or four times 
their volume of water and heated on a water-bath. As soon as 
coagulation sets in, a few drops of a 0.3 to 0.5 per cent, solution 
of acetic acid are added until a feebly acid reaction is obtained. 
After having been kept upon the boiling-water bath for from fifteen 
to twenty minutes longer, until the albumin has separated out and 
settled in brownish flakes, the mixture is filtered while hot, and 
the precipitate washed repeatedly with hot water. Filtrate and 
washings, which usually present a' slightly yellow or brownish color, 
are again brought to the boiling-point after the addition of 0.3 to 
0.5 per cent, of acetic acid, decanted, filtered, and after the addition 
of a small amount of disodic phosphate further treated according 
to the Ludwig-Salkowski method (see Urine). The first filtrate is 
then treated with hydrochloric acid, evaporated to about 10 c.c, and 
allowed to stand for twenty-four hours, when the uric acid that has 
separated out is filtered off through asbestos or glass-wool. The 
filtrate may then be examined for xanthin-bases according to the 



THE PBOTEIDS OF THE BLOOD. 55 

Bame method. It' qo uric acid crystallizes out, as not infrequently 
occurs, the acid fluid is directly examined for uric acid by means 
of the murexid test (which sec). It' upon the addition of ammonia 
no distinct red color develops, the residue, after thorough desicca- 
tion, is dissolved in water, when a reddish color may be regarded 
as indicating the presence of uric acid, while a yellow or brown 
color is referable to xanthin-bas/s. Hopkins' method may also be 
used. 

Garrod's Test. — This test may be advantageously employed if it 
is desired merely to determine whether or not large amounts of uric 
acid are present in the blood. A few cubic centimeters of blood- 
serum (5-10) or of serous fluid, obtained by means of a blister, are 
placed in a watch-crystal and treated with from six to ten drops 
of a 30 per cent, solution of acetic acid. A linen thread is im- 
mersed in the fluid, which is then kept at a low temperature for 
from twelve to twenty-four hours. At the expiration of this time a 
few uric acid crystals will have separated out upon the thread, if the 
substance is present in large amounts. The true nature of these 
crystals may then be further determined by the microscope and the 
murexid test (see Uric Acid in the Urine). 

Literature. — Picard, Yhvhow's Archiv, vol. ii. p. 189. Garrod, Med.-Chir. 
Trans.. 1854, p. 4!). Salomon. Zeit:. f. physiol. Cbem.. vol. ii. p. 65 ; and Charite Annalen, 
1—D. vol. v. p. 137. Klemperer, Dentseh. med. Woch., 1895, No. 40. Weintraud, 
Ibid.. V. B. p. 185. 

Xanthin-bases. — Xanthin-bases do not occur in normal blood or 
are present only in exceedingly small amounts. Under pathological 
conditions, however, they may be encountered in recognizable quan- 
tities, as in leukaemia, typhoid fever, lymphatic tuberculosis, emphy- 
sema, phthisis pulmonalis, pleurisy, and chronic nephritis. 

The method above indicated for the demonstration of uric acid 
in the blood should also be employed when it is found desirable to 
test for these bodies (see Urine). 

Literature.— A. Kossel, Zeit. f. physiol. Ohem., 1882, vol. vii. p. 22. Scherer, Ver- 
handl. d. physik. med. Ges. z. Wiirzburg, 1852, vol. ii. p. 325. 

Fat and Fatty Acids. 

An increase in the amount of fat which is normally present in 
the blood, to the extent of from 0.75 to 0.85 per cent., aside from 
that arising after the ingestion of large amounts of fatty food, is 
met with iu cases of obesity, chronic alcoholism, iu phosphorus 
poisoning, in injuries affecting the long bones and the spinal cord, 
in various hepatic diseases, chronic nephritis, tuberculosis, malaria, 
cholera, during starvation, pregnancy, in infants at the breast, etc. 
The greatest increase, however, is observed in cases of severe diabe- 
tes, in which amounts varying between 1.27b' and 1 1.7 per cent, have 
been encountered. In such cases fat emboli may be found post mor- 



■!o THE BLOOD. 

tem plugging the vessels of various organs, and notably the brain, the 
lungs, and the kidneys. This increase in the amount of fat constitutes 
the condition spoken of as Jipmnia. The term Upaeidcernia has been 
applied to the occurrence of volatile tatty acids in the blood, noted 
by v. Jaksch in various febrile diseases, leukaemia, and at times in 
diabetes, in which this condition is supposed to stand in a causative 
relation to the coma. ; i-oxy butyric acid has been found post mor- 
tem in the blood in diabetes. 

To demonstrate the presence of tat in the blood, it is best to pre- 
pare cover-glass specimens, and to mount these in a drop of a 5 per 
cent, solution of osmic acid. The fat droplets are thus colored 
black, and appear about as large as the finest fat granules which are 
found in milk or butter. They may also be stained with Sudan III., 
and are thus colored red. In every case the necessary instruments 
and glasses should be carefully cleansed with ether, so as to avoid 
the accidental introduction of fat 

To test for fatty acids, 20 to 30 c.c. of blood, obtained by means 
of cupping-g as 5, are treated with an equivalent weight of sodium 
sulphate and boiled. The nitrate is then evaporated to dryness and 
extracted with absolute alcohol. Upon evaporation of this solution 
lattv acid crystals will be obtained, which can readilv be recognized 
with the microscope (see Feces 

Literatc-be- — M. Bonninger. u On the Methods for the Estimation of Fat in the 
Blood, and the Amour,: : Faf in Hnman Blood." Zeit. f. klin. Med., vol. xlii. Parts 1 
and 2L T. B. Fnteber, 'Iipsenria in Diabetes Mellitns/ r Jomr. Am. Med. Assoc 1899, 
p. 1006. Su Watjofi; "Feber d. Fettgehalt d. Blutes b. Vierenkrankheiten/' Deutsch. 
med. Woch.. 1892 I 559. v. Jaksch, "lipaeidaemie," Zeit. f. klin. Med., vol. xi. 

Lactic Acid. 

There appears to be some doubt whether or not lactic acid nor- 
mally occurs in the blood of man during life. In the blood of dogs, 
however, Gaglio conld always demonstrate the presence of the acid 
during the process : :igestion. after feeding with meat. The 
amount varied between 0.3 and 0.5 pro mille. During starvation 
smaller amounts were found, but it never disappeared altogether. 
In one instance Gaglio obtained 0.17 pro mille after fasting for 
forty-eight hours. Similar results were obtained by Irisawa, who 
noted 7 moreover, that the amount of lactic acid in the blood stood in 
direct relation to the c _ : : ancemia which was produced. 

In the human being Irisawa found lactic acid fairly constantly 
after death, the amount, determined as zinc lactate, varying between 
0.233 and 6. 575 pro mille. These extensive variations he was unable 
to explain by the character of the disease causing the fatal termina- 
tion, and it is possible that the cause therefore lies in the fact that 
in some cases the blood was obtained shortly after death, while in 
others many hours had elapsed, as Irisawa himself suggests. 

The following method may be employed : 100 to 300 c.c. of blood 



THE PR0TEID8 OF THE BLOOD. 57 

are extracted with three times its volume of alcohol, filtered, and 
the filtrate evaporated to a syrupy consistence. This is then made 
stroogly alkaline with barium hydrate and shaken with Large quan- 
tities of ether, in order to remove the fats which are present. The 

residue is acidified with phosphoric acid and again shaken with ether 
tor twenty minutes at a time, until the process has been repeated 
five or six times, the lactic acid passing over into the ether. The 
ether is distilled off from the extract, the residue taken up with 
water, and the solution carefully evaporated in order to drive off any 
ether still remaining, as well as the fatty acids. Carbonate of zinc 
is now added and the solution heated to 100° C. and filtered. The 
nitrate is evaporated on a water-bath until crystallization begins, 
when it is allowed to cool and treated with a few drops of absolute 
alcohol, in order to effect a complete separation of the lactate of zinc. 
The solution is allowed to stand exposed to the air until a constant 
weight is obtained. 

Literature.— G. Gaglio, " Die Milchs'aure d. Blntes," Du Bois Archiv, 1886, p. 400. 
T. Lrisawa, " (Jeber d. Milchsiiure im Blut und Harn," Zeit. f. physiol. Chem., 
1892, vol. xvii. p. 349. 

Biliary Constituents. 

Biliary constituents — i. e., bile-pigment and biliary acids — are not 
encountered in the blood under normal conditions, but are found 
whenever they are present in the urine (which see). It is noteworthy, 
furthermore, that bilirubin may frequently be demonstrated in the 
blood when a urinary examination in this direction yields negative 
results. According to v. Jaksch, 1 moreover, bilirubin occurs in the 
blood in nearly every case in which urobilin exists in the urine, 
which suggests that bile-pigment circulating in the blood may possi- 
bly be transformed into urobilin in the kidneys. 

A chokemia is encountered in the various pathologic conditions 
which are associated with a resorption of bile, as in obstructive 
jaundice, in association with an excessive elimination of bile into 
the intestinal canal, as well as with an increased destruction of red 
corpuscles. 

In order to test for biliary acids, the blood is first treated with 
alcohol, in order to remove the proteids. The biliary acids which 
are present in the filtrate are next transformed into their lead salts 
by means of lead acetate and ammonia, and thus precipitated. 
After washing with water the precipitate is boiled with alcohol and 
filtered. The lead salts are decomposed by means of sodium carbo- 
nate, the solution is again filtered, the filtrate evaporated to dryness, 
and the residue extracted with absolute alcohol. The alcohol is dis- 
tilled off, when the biliary salts of sodium will crystallize out or 
remain behind as an amorphous mass, which may be tested directly 

1 v. Jaksch, Clinical Diagnosis, 4th ed., 1896, p. 97. 



58 THE BLOOD. 



according- to Pettenkofer's method. To this end. some of the residue 
is dissolved in water and treated with two-thirds of its volume of 
concentrated sulphuric acid, care being taken that the temperature 
does not rise beyond 60° C. To this mixture a few drops of a 20 
per cent, solution of cane-sugar are added, when in the presence of 
biliary acids a beautiful violet color is obtained, which is referable 
to the action of furfurol. formed from the cane-sugar and the acid, 
upon the biliary acids. 

Bilirubin can be demonstrated in the blood most readily in the 
following manner: 10 to 15 .: blood obtained by means of 

cupping-glasses, are allow-, gulate. when the serum is removed 

by means of a pipette, filtered through asbestos, and coagulated in 
as thin a layer as possible at a temperature of 80 c C. Under such 
conditions normal seruni presents a light straw color, while in the 
presence of biliary coloring-matter a light greenish color is seen, 
winch becomes grass green on standing. Should the serum contain 
haemoglobin, as in htenioglobinamiia. a brownish color results. 

Acetone. 

Acetone has been found in the blood in considerable amounts 

under various pathological conditions, and especially in fevers. 

In order to demonstrate its presence, the blood is first extracted 
with ether and subsequently distilled, when the distillate is tested as 
indicated elsewhere sec Acetonuria . 

Di iige?s test may also be employed, and has the advantage of 
_ ater simplicity : 3 c.c. of blood are treated with about 30 cc of 
Dennigt-'s reagent and allowed to stand until the dark-brown precipi- 
tate has settled to the bottom. The supernatant fluid is filtered off 
and treated with a little more of the reagent, so as to insure complete 
precipitation. It is then acidified with sulphuric acid and heated as 

- ribed. The formation of a white precipitate, which is soluble 
in an excess : hydrochloric acid, is referable to acetone or diacetic 
acid. 

Litebatubz. — v. Jaksch. AcetoBuxie u. Diaceturie. Berlin. 1S55. Eeale. Schmidt's 
Jahrbueh.. 1892, p. 106 Extract . 

MICROSCOPICAL EXAMINATION OF THE BLOOD. 

The Red Corpuscles. 

Variations in the Size of the Red Corpuscles. — If a drop of 
1. most readily obtained from the tip of a linger or the lobe of 
the ear. is examined with the microscope, a large number of faintly 
greenish-yellow. n<:.n -nucleated, circular, biconcave disks will be 
served — the red corpuscles, oi ervthroevtes. of the blood Plate II., 
Fig. 1. A . 



PLATE II 



f 



W*# •■ * 



thi 



ifis* 



mm 









Q | 



* 



Elements of Normal 
Blood. 

i, Small Mononuclear Leucocyte; 
2, Neutrophilic Leucocytes; 3, Eosino- 
philic Leucocyte ; 4, Normal Red Blood 
Corpuscles. Unstained Specimen. 






Poikiloeytosis. 

Unstained Specimen taken from a 
Case of Pernicious Anaemia. (Per- 
sonal Observations.) 



FIG. 2. 




OO 











O 



The Various Elements of the Blood Stained with Ehrlieh's Tri-aeid Stain. 
Small Mononuclear Leucocytes; 2, Large Mononuclear Leucocytes; 3, Transition Form ; 4. Neutrophilic 
Leucocytes; 5, Myelocyte; 6, Eosinophilic Leucocyte; 7, Melaniferous Leucocyte: 8, Normo- 
blast ; 9, Megaloblast : 10, Normal Red Corpuscles. (Personal Observation.) 



PLATE III. 




J 



-:-•<. 




<%£•> 




The Blood of Pernicious Anaemia. 

Note (a) the variations in the size and form of the red corpuscles ; (5) the existence of polychromato- 
philic (i) a and granular b (2) degeneration in some of the red corpuscles ; (c) thepresence of nucleated 
red corpuscles, both of the normoblastic (3) and megaloblastic type (4); {d) the presence of free nuclei 
(5), derived from nucleated red corpuscles. (Bausch and Lomb, Eye-piece 1 inch, objective i-i2th.) 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 59 

Under normal conditions variations in the size of the red corpus- 
cles arc observed, and Hayem 1 distinguishes between corpuscles of 
average size, measuring from 7. '2 a to 7.8 u in diameter, small cor- 
puscles, presenting an average diameter of from G p. to 6.5 /i, and 
large corpuscles, measuring from 8.5 u to 9 ju. 

In certain diseases which arc accompanied by a marked oligo- 
cythemia both abnormally small and large corpuscles are encoun- 
tered, which have been termed microcytes and macrocytes, respectively. 
The former measure from 3.5 u to 6 u ; the latter, from 9.5 fi to VI u 
in diameter. Still larger forms, the megalocytes, or giant corpuscles 
of Hayem, are also seen at times, of which the diameter measures 
from 10 u to 1G a. These latter are of especial interest, as their 
presence in large numbers appears to be confined almost entirely to 
the blood of pernicious anaemia. In chlorosis they are far less 
common (Plate III.). 

The terms microcyiheemia and macrocythcemia have been applied 
to conditions in which the smaller or the larger Yorms, respectively, 
predominate in the blood. While there appears to be no doubt that 
a true macroeythaemia exists in the circulating blood in various forms 
of anaemia, and while microcytes also may occur as such in the cir- 
culating blood, these are only exceptionally met with, the ordinary 
microevthaemic condition, according to Hayem, being artificially 
produced during the preparation of the specimen, so that this term 
really conveys a wrong impression, and should be discarded. Al- 
though admitting the correctness of Havem's view to a certain 
degree, there can be no doubt that under pathological conditions 
abnormally small red corpuscles are quite constantly met w r ith in 
large numbers, be they pre-existent as such in the circulating blood 
or produced artificially during the preparation of the specimen. 
They are thus seen accompanying the condition of macrocythaemia, 
in pernicious anaemia, leukaemia, the pseudoleukaemic condition of 
children, the various severe forms of anaemia in general, and even 
in chlorosis. 

Variations in the Form of the Red Corpuscles. — Going hand 
in hand with variations in the size of the red corpuscles are varia- 
tions in form which affect not only the microcytes and macrocytes, 
but also the corpuscles of normal size (Plate II., Fig. 1, B). Cor- 
puscles are thus seen which resemble a flask, a kidney, a biscuit, 
a boat, a balloon, a dumb-bell, an anvil, etc.; while others, again, 
are SO irregular in appearance that it is impossible to compare them 
with any object. Very characteristic also are the oval red corpus- 
cles so commonly seen in pernicious anaemia. Especially inter- 
esting is the fact that such corpuscles may manifest certain move- 
ments in the fresh preparation, and that they have been mistaken 
at times for amoebae and similar organisms. 



Hayem, Le sang, Paris, 1891. 



60 THE BLOOD. 

The term poikiloeytosis has been applied to alterations both in the 
size and in the form of the red corpuscles. This condition may be 
observed in the various forms of anaemia, and is especially pro- 
nounced in pernicious anaemia, of which disease it was once thought 
to be pathognomonic. In chlorosis, poikiloeytosis is usually seen 
only in the most severe cases, and particularly in those manifesting 
a tendency toward thrombosis and embolism. 

Variations in the Number of the Red Corpuscles. — The num- 
ber of red corpuscles in the blood of healthy individuals is quite 
constant, and the statement generally found in text-books that 
5,000,000 to 5,500,000 are contained in every cbmm. of blood in 
the adult male and 4,500,000 in the adult female is fairly accurate. 

A somewhat higher average is found among people living at a 
considerable elevation above the sea-level, and it is interesting to 
note that an increase in the number occurs whenever a change in 
the habitation is made from a lower to a higher level. This increase 
is frequently marked, as is apparent from the following table, taken 
from Ehrlich : l 

Altitude. Increase of. 

561 meters 800,000 

700 " 1,000,000 

1800 " 2,000,000 

4392 " 3,000,000 

A corresponding diminution occurs when a change is made from 
a higher to a lower level. 

An apparent increase in the number of red corpuscles may 
be met with in all conditions in which a concentration of the 
blood as a whole occurs, as in profuse diarrhoea, vomiting and 
sweating, in connection with the rapid accumulation of serous effu- 
sions, during starvation, viz., the withdrawal of liquids, etc. In 
such cases counts of 6,000,000 and more may be obtained. There 
are other conditions, however, in which an apparent increase in the 
number of the red corpuscles occurs, and in which this increase is 
not due to a concentration of the blood as a whole. This is notably 
the case in diseases of the adrenal glands, in which counts of 
6,000,000 and 7,000,000 have repeatedly been obtained, although the 
color index of the individual corpuscles was distinctly subnormal. 
The supposition is that in such cases a stasis of large quantities of 
blood occurs in the abdominal viscera, leading to oligaemia of 
the peripheral organs. But in consequence of the fact that the 
amount of plasma which is available for the nutrition of these parts 
corresponds to a smaller amount of blood, a localized concentration 
occurs, of which the polycythemia is the outcome. 

Stengel 2 states that in chronic heart disease, with continued inade- 

1 P. Enrich u. A. Lazarus, "Die Anaemie," Nothnagel's Specielle Path. u. Therap., 
vol. viii. Part 1. 

2 A. Stengel, Proc. Path. Soc. Phila., 1899. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 61 

quacv of the circulation of slight degree, polycythemia is frequently 
observed, while in congenital hearl disease the number of the red 
cells may reach 8,000,000 per cbmm. According to Grawitz, this 
is due to loss of liquid from the blood, owing to the continued low 
blood-pressure and vascular dilatation. Stengel, on the other hand, 
believes it to be due to a disturbance in the normal distribution of 
the corpuscles. 

Oertel and Grawitz ' further have pointed out that a polycythemia 
occurs in conditions which are associated with chronic stasis, cyanosis, 
and oedema, and is more marked in the capillaries than in the arter- 
ies and veins. 

An increase is observed also in diabetes, but is not dependent 
upon a concentration of the blood, as it may also be seen following 
an increased ingestion of fluids, as well as while fasting. While 
there can thus be no doubt that a polycythemia may occur, experi- 
ments have demonstrated almost conclusively that such a condition 
does not exist in what is generally spoken of as true plethora, and 
that the various symptoms of plethora formerly attributed to an 
increase iu the total amount of blood or of the red corpuscles are 
referable more likely to vasomotor disturbances. 

A diminution in the number of red corpuscles, on the other hand, 
is more frequently observed ; it may be temporary or permanent. 
An olio-ocvthemia may occur in all forms of anaemia, of wdiatever 
origin, and the number may fall to 360,000 and even lower in fatal 
cases. In pernicious anemia the lowest figures have been noted, 
and Quincke 2 cites a case in which just before death only 143,000 
red corpuscles were counted in the cbmm. 

When the anemia is progressive the body apparently becomes 
habituated to the diminution in the number of red corpuscles, and 
it is surprising to find individuals attending to the duties of everyday 
life with a blood-count of only 2,000,000, or even less. It is not 
uncommon to meet with cases of pernicious anemia in hospitals in 
which the patients with only 500,000 corpuscles have not been 
obliged to go to bed. Nevertheless, it must be admitted that when- 
ever the number falls below this figure recovery is probably out of 
the question. A sudden reduction in their number to 1,000,000, 
moreover, is usually followed by a fatal result. 

In chlorosis the oligocythemia is generally not marked. Cabot 3 
thus found 4,050,000 red corpuscles per cbmm. as the average in 
his series of seventy-seven cases — in other words, nearly normal 
values. At times, however, cases are met with in which the dim- 
inution of the red corpuscles almost keeps step with the diminution 

1 Oertel. Deutsch. Arch. f. klin. Med., vol. 1. p. 29?,. 

2 Quincke, " Ueber perniciose Anaemie," Centralbl. f. d. med. Wiss., 1877, No. 47; 
and " Weitere Beobachtungen uber progressive perniciose Anaemie," Deutsch. Arch, 
f. klin. Med . vol. xx. 

3 R. C. Cabot Clinical Examination of the Blood. Wm. Wood & Co., 1897. 



62 THE BLOOD. 

in the amount of haemoglobin. Hayem thus mentions an instance 
of chlorosis in which only 937,360 red corpuscles were counted 
in the cbmm. Such cases, of course, are rare. 

In leukaemia a more than moderate oligocythemia is likewise not 
the rule, and is more common in the lymphatic than in the myelogen- 
ous form. The average figures which Cabot l gives are 2,730,000 
and 3,120,000, respectively. 

In Hodgkin's disease a marked diminution is also unusual. 

In the secondary anaemias, even in advanced cases, the oligocy- 
themia may not be very marked, excepting the anaemias of infancy 
and early childhood, following profuse hemorrhages, in malaria, and 
in acute septicaemia. 

The post-typhoid anaemia is, as a rule, not very severe, but ex- 
ceptional cases occur in which the diminution in the number of the 
red corpuscles is considerable. Osier thus cites an instance in which 
the number fell to 1,300,000 per cubic millimeter. 

In acute gastritis and usually in chronic gastritis, also, the num- 
ber of the red- corpuscles is not diminished, while in carcinoma a 
marked oligocythemia occurs at some time in the course of the disease. 
In the earlier stages, however, this is often but little marked, and at 
times even an apparent increase of the red cells is noted. Later a 
diminution is probably always found. In the severer forms of 
chronic gastritis a diminution is also fairly constant, but rarely so 
marked as in carcinoma, if we except those cases of gastric anadeny 
which present the clinical picture of a pernicious anemia. In the 
differential diagnosis between carcinoma of the stomach and per- 
nicious anemia a count below 1,000,000 points to the latter disease. 
In ulcer of the stomach normal values are found unless hematemesis 
has recently occurred or unless the disease is associated with pro- 
found chlorosis. 

In acute endocarditis Stengel 2 has noted a rapid fall of the red 
corpuscles, often to 50 or 40 per cent. 

Variations in the Color of the Red Corpuscles. — As the inten- 
sity of the color of the individual corpuscle depends upon the amount 
of hemoglobin which it contains, and is more marked along the 
periphery than in the centre, a deficiency of hemoglobin may be 
recognized at once. In a moderate grade of anemia the entire 
corpuscle will thus appear paler than normally, and the pallor will 
naturally be more marked in the centre. In the severer forms this 
becomes still more apparent, and corpuscles may then be met with 
in which only a narrow rim of hemoglobin can be discerned along 
the periphery, while the centre appears colorless. Such forms have 
very appropriately been compared to pessaries, and are hence spoken 
of as " pessary forms. " This appearance can readily be made out 

1 Loc. cit. 2 Loc. cit. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 63 

upon examination of a fresh specimen, but is especially marked in 

stained preparations. 

Curiously discolored red corpuscles, presenting a bronzed appear- 
ance, are frequently observed in malarial blood. Their appearance 
sh >uld always excite suspicion, and lead t<> a careful examination for 
malarial organisms. The discoloration is in all probability evidence 
of a degenerative process. 

Behavior toward Anilin Dyes. — Under normal conditions the 
red corpuscles are stained only with acid dyes, such as eosin, 
orange G, and others. In various forms of anaemia, on the other 
hand, tin- property is lost to a greater or less extent, while a certain 
affinity for basie stains becomes manifest. This is readily seen in 
blond specimens which have been taken from cases of chronic anaemia, 
and have been stained with ha?matoxvlin-eosin, eosin-methylene-blue, 
or the eosinate of methylene-blue (see pages 99—103). In such 
preparations the majority of the red corpuscles will be stained red, 
but individual corpuscles will also be seen in which a blue tint is 
more or less apparent. In some this can be made out only indis- 
tinctly, while others show" a very manifest bluish-red color, others a 
reddish blue, and still others a violet or even a deep, pure blue. A 
brownish color, moreover, is at times seen in severe forms of ansemia 
(see Plates III. and VI.). Similar pictures are obtained with 
Ehrlich's tri-aeid stain, but are not so well defined. This altered 
behavior of the red corpuscles toward the anilin dyes has been 
ascribed to certain degenerative processes which take place, in the 
red blood-corpuscles, and the phenomenon has hence been termed 
anceinic or polychromatophilic degeneration. 

As I have already indicated, this degeneration is observed in 
various forms of anaemia, and may affect not only the non-nucleated, 
but also the nucleated red corpuscles, and especially the megaloblasts. 
The peculiar coppery tint of some of the red corpuscles which is 
observed so frequently in malarial blood is probably also refer- 
able to such degenerative changes. According to some observers, 
the polychromatophilia of the red cells is not referable to degen- 
erative changes, however, but is the expression of blood regen- 
eration, the polychromatophilic cells representing the youngest 
red cells of the blood. This view is essentially based upon the 
observation that polychromatophilic cells are normally encountered 
in the embryo, and that they are especially numerous in the circu- 
lating blood shortly after severe hemorrhages and in other condi- 
tions in which an active blood regeneration is going on. Such 
cells have also been found in the marrow of various healthy 
domestic animals, and I have myself seen them in the blood of 
the squirrel, the sea gull, and the frog. 

Literature.— Ehrlich, Charite Annalen, vol. x. p. 136. Engel, Deutseh. med. 
Woch., 1899, p. 20!). Gabritschewsky, Arch. f. exp. Path., vol. xxviii. p. 83; Zeit 
f. klin. Med., vol. xxvii. p. 492. Askanazy, Ibid., vol. xxi. p. 415. Maragliano and 
Castellino. Ibid., vol. xxi. p. 415. 



64 THE BLOOD. 

Very interesting and important is the observation of Bremer, 
that a distinct difference exists in the affinity of diabetic blood for 
certain anilin dyes, as compared with non-diabetic blood. For, 
whereas non-diabetic blood is readily stained with Congo-red, 
methyl-blue, eosin, etc., diabetic blood is distinctly refractory, 
while such dyes as Biebrich-scarlet, which readily stain the diabetic 
blood, do not color non-diabetic blood. Upon this peculiarity in 
the behavior of the red corpuscles Bremer's diabetic blood test is based. 

Method. — A drop of blood of moderate size is mounted on a 
slide and spread out in a wave-like manner, using the edge of a 
second slide for this purpose. A number of such preparations are 
made, as also an equal number with normal blood for control. 
These are then placed on the tray of a drying-oven at a distance 
of 12 cm. from the bottom. The bulb of the thermometer is fixed 
at the same level. The temperature is then rapidly raised to about 
130° C, when the flame is removed. Care should be taken that 
the temperature thereafter does not exceed 140° C; the optimum 
lies at about 135° C. The apparatus is then allowed to cool until 
the preparations can be conveniently handled, when a specimen of 
the diabetic blood is placed back to back with a control-specimen, 
and both are immersed in the staining fluid. A 1 per cent, aqueous 
solution of Congo-red, which should always be made up freshly 
when required, is advantageously employed. After exposure for 
from one and a half to two minutes the specimens are rinsed in 
water and dried with filter-paper. It will then be seen that the 
non-diabetic blood is stained the color of Congo-red, while the 
diabetic blood is either not stained at all or presents merely an 
orange color. 

Other stains may also be employed, such as a 1 per cent, aqueous 
solution of methyl-blue or Biebrich-scarlet, or Ehrlich's tri-acid 
stain, the eosinate of methylene-blue, and others. When using 
methyl-blue analogous results are obtained as with Congo-red. 
With Biebrich-scarlet, on the other hand, the diabetic blood takes 
up the color, while the non-diabetic specimen proves refractory. 
If Ehrlich's stain is employed, an exposure to the stain for from 
two to five minutes is necessary ; the diabetic specimen is stained 
orange, the non-diabetic blood violet. 

Very satisfactory results are obtained also w T ith the following 
method : the preparations are first stained for from one and a half to 
two minutes in a 1 per cent, aqueous solution of methyl-green. Upon 
washing, it will be seen that both specimens are colored green, but 
the diabetic blood more markedly so than the other. Both are then 
immersed for from eight to ten seconds in a 0.12 per cent, aqueous 
solution of eosin, w 7 hen the diabetic blood remains green, while the 
non-diabetic specimen is colored eosin. Analogous results are 
obtained with methylene-blue and eosin. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 65 

Success in these examinations depends essentially upon the proper 
degree of temperature during the process of fixation. Bui care 
should also be had not to leave 4 the specimens in the staining solu- 
tion longer than indicated, and to rinse quickly in water and dry. 

I have used this method in some ten eases of diabetes with very 
satisfactory results, and have likewise obtained a positive reaction 
at times when the sugar had temporarily disappeared from the urine. 
As a control to the urinary examination, the method is certainly of 
value. 

Regarding the nature of the substance in diabetic blood which is 
responsible for this peculiar behavior, little is known, but it appears 
certain that the reaction is not dependent upon the presence of glu- 
cose nor upon the degree of alkalinity of the blood, as suggested 
by Lepine and Lyonnet. Bremer's claim that the reaction is pathog- 
nomonic of diabetes and glucosuria, and may even yield positive 
results in the pre-diabetic stage of the disease, and when the sugar 
has temporarily disappeared from the urine, has been confirmed in 
all essential points, both in this country and abroad. A few inter- 
esting exceptions, however, have been noted. In animals, for 
example, in which glucosuria has been artificially produced by 
means of phlorhizin, the reaction does not occur, whereas in phloro- 
gluein-diabetes positive results are obtained. In Bremer's entire 
series of diabetic cases a negative result was obtained but once, and 
in this instance he believes that the diabetes was of the renal type, 
and analogous to the phlorhizin-diabetes of animals. He suggests 
that it may thus be possible to differentiate this form from the 
hematogenic variety, using the latter term in its widest sense. 
Lepine and Lyonnet report a positive result in one case of leukae- 
mia, but Bremer believes this to have been due to faulty technique. 
Hart wig believes that Bremer's reaction is constant in diabetes, but 
states that it may occur at times in other conditions. 

Literature. — L. Bremer, "An Improved Method of Diagnosticating Diabetes 
from a Drop of Blood," N. Y. Med. Jour., 1896 ; Centralbl. f. inn. Med., 1897, p. 521. 
Le Goflf, Ileact. chrom. du sang diabet., Paris, 1897. Lepine and Lyonnet, Lyon med., 
vol. lxxxii. p. 187. Hartwig, Deutsch. Arch. f. klin. Med., vol. lxii. p. 287. 

Granular Degeneration of the Red Corpuscles. — In certain 
forms of anaemia, notably in pernicious anaemia, in leukaemia, in 
pseudoleukemia, in cases of chronic lead poisoning, in the cachexias 
associated with severe septic infection, with malaria, syphilis, car- 
cinomatosis, and the final stages of tuberculosis, red corpuscles may 
be encountered which contain basophilic granules in variable num- 
bers. These granules are readily stained with methylene-blue, with 
the eosinate of methylene-blue, with Ehrlich's haematoxylin-eosin 
solution, etc. Methyl-green, on the other hand, which is a strong 
nuclear dye, does not stain the granules. Their size and form are 
somewhat variable. While the majority are round, others are rod- 

5 



66 THE BLOOD. 

like or biscuit-shaped, and frequently arranged in pairs, resembliug 
gonococci. As a general rule, they are seen in the interior of red 
blood-corpuscles, but I have found them also free in the plasma 
(Plates III. and IV.). They may occur in cells of normal size and 
coloration, in poikilocytes, and even in nucleated red blood-corpus- 
cles, both of the normoblastic and megaloblastic tvpe. Xot infre- 
quently they are seen in cells which are undergoing polvchroma- 
tophilic degeneration. 

Engel, Ehrlich, and others have suggested that these granules are 
essentially karyolytic products ; but Grawitz maintains, and I think 
rightly so, that they are not of nuclear origin. They may be found 
at a time when nucleated red corpuscles cannot be demonstrated in 
the blood ; nucleated cells in which no sign of karvolvsis can be 
discerned may be studded with the granules ; unlike the nuclei of 
such cells, the granules show no affinity for methyl-green, and, in fine, 
examination of the bone-marrow does not show evidence of the 
existence of karyolytic processes. Granular red cells are not found 
in the marrow even when they are numerous in the circulating 
blood. Grawitz hence regards their presence as indicative of a 
degenerative change in the haemoglobin, and has termed the phe- 
nomenon " granular degeneration." 

Schmauch has observed similar appearances in the blood of cats. 
Engel has described such granular corpuscles in the blood of early 
cat embryos, and I have found them in that of the squirrel. Their 
significance under such conditions is unknown. In man they 
are never seen under normal conditions, and their presence may 
always be regarded as a symptom of haemolysis of a grave type. 
I have found them in pernicious anaemia, in malaria, and in a case 
of lymphatic leukaemia. In chlorosis and in the anaemia of chronic 
nephritis they are absent. In a case of v. Jaksch's anaemia, in which 
nucleated red corpuscles were quite numerous, I also obtained nega- 
tive results. In one case of pernicious anaemia in which they were 
especially numerous many of the cells presented a well-marked 
polychromatophilia ; but, like Grawitz, I do not believe that the 
polychromatophilia represents an early stage of granular degenera- 
tion. 

Especially important is the presence of such corpuscles in cases 
of chronic lead poisoning, in which they may be found at a time 
when clinical symptoms are not as yet manifest. AVith improvement 
of the general condition they gradually disappear, and the same 
holds good for those cases of pernicious anaemia which develop 
upon the basis of an auto-intoxication referable to the gastro- 
intestinal tract. 

In the early stages of phthisis granular degeneration is not 
observed, but it may occur when a septic condition has supervened. 

In white mice Grawitz was able to produce granular degeneration 



PLATE IV. 




k^jtUtM.ir 



The Blood of Myelogenous Leukaemia. 



Note the large increase of the leucocytes, and the presence of nucleated red corpuscles of the nor- 
moblastic type (i). In addition to the leucocytes, found in normal blood, viz., (2) mononuclear leuco- 
cytes, devoid of granules, and of polynuclear neutrophilic (3) and eosinophilic leucocytes (4), 
myelocytes, both of the neutrophilic (5) and eosinophilic (6) variety, are also seen. (Bausch and 
Lorab, Eye-piece 1 inch, objective 1-12U1.) 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 07 

of the red corpuscles by prolonged exposure of the animals to a 
temperature of from 37 c to l<> C. He therefore suggests that the 
analogous results which were obtained by Plehn in the cast- of 

Europeans after a brief sojourn in the tropics may possibly be 
referable to the high temperature. 

Literature. E. Grawitz, "Ueber Kornige Degeneration d. rothen Blutzellen," 
Dentsch. med. Woch., 1899, No. 36, p. 585; "Klinische Bedeutung a. experiment. Er- 
zeugang korniger Degenerationen," etc., Berlin, klin. Woch.. 1900, p. L81 ; "Granular 
Degeneration of the Erythrocytes," etc., Am. .lour. Mod. Sci., 1900, vol. cxx. p. 277. 
Bloch, Deutsch. med. Woch., 1899, V. B. p. 279. Littcn, Ibid., No. 44. Behrendt, 
Ibid., No. it. "Granular Degeneration of the Erythrocyte," Am. Jour. Med. Sci., 
1901, vol. exxii. p. 266. 

Nucleated Red Corpuscles. — Three varieties of nucleated red 
corpuscles may be seen. For their study, however, dried and 
stained preparations are indispensable, as the nuclei can scarcely 
be made out in fresh specimens. 

1. Normoblasts.— These are nucleated red corpuscles of the 
size of an ordinary red corpuscle, and appear to be identical with 
those normally found in the bone-marrow of adults. The nucleus, 
which frequently shows signs of undergoing division, is usually 
located centrally, although an excentric position may also occur. 
They are further characterized by the great avidity with which the 
nuclei take up the nuclear dyes (Plate II., Fig. 2 ; Plates III. and 

IV -)- 

In specimens of blood in which normoblasts are numerous, as in 
myelogenous leukaemia, many cells are seen in which the protoplasm 
surrounding the nucleus is much diminished in amount, and pre- 
sents a ragged outline. Such cells, in my experience, always pre- 
sent evidence of polychromatophilic degeneration, and are at times 
mistaken for poorly stained lymphocytes. They are manifestly 
undergoing destruction. 

Free nuclei, which undoubtedly are derived also from normoblasts, 
may likewise be seen in the blood. 

Normoblastic red corpuscles are quite constantly found in all 
forms of severe anaemia, whether this be the result of traumatism, 
of inanition, or organic disease. In the acute anaemias they are 
apt to be most numerous ; but even in the chronic forms and in 
cachectic conditions specimens of blood may be obtained in which 
one or more are seen in almost every field. In his recent work on 
Anosmia Ehrlich l cites a case of hemorrhagic anaemia, reported by 
v. Xoorden, in which temporarily the normoblasts were so numer- 
ous, while hyperleucocytosis existed at the same time, that the 
blood closely resembled that seen in myelogenous leukaemia. As 
this condition was associated with an increase of the red corpuscles 
to almost double their original number, v. Noorden very aptly 
termed it a " blood-crisis." 

1 Loc. cit., p. 41. 



68 THE BLOOD. 

For the accurate determination of a blood-crisis the following 
examinations are necessary : 

a. A determination of the absolute number of the red corpuscles. 

b. A determination of the ratio between the white and red cells. 
e. A determination of the ratio between the nucleated red and 

white cells, in dried specimens, with the aid of the quadratic ocular 
diaphragm. 

Example. — Supposing that in a given case 3,500,000 red corpus- 
cles are found in the cbmm.. while the ratio of the white to the red 
corpuscles is 1 : 100. and that of the nucleated red to the white 
1:10; 3500 nucleated red corpuscles mu>t hence be present in 
each cbmm. of blood — i. c. one for each thousand of normal red 
corpuscles. 

Whenever the number of red corpuscles falls below 1,500,000 
and normoblastic cells are not present, the disease will probably end 
fatally. 

2. Megaloblasts. — These bodies are from two to four times as 
large as the normal red corpuscles, measuring from IT) >,. to 20 ji 
in diameter. They are provided with a large nucleus, which, accord- 
ing to Ehrlich. never shows signs of undergoing division and does 
not stain nearly so deeply as the normoblastic nucleus (Plate II., 
Fig. 2, and Plate III. |. In some specimens, indeed, the affinity 
for nuclear dyes is so little marked that at first sight a nucleus can 
scarcely be discerned. 

At times abnormally large megaloblasts are seen — the giganto- 
blasts of Ehrlich. 

Under normal conditions megaloblasts are found in the blood of 
very young infants, but they are present only in small numbers. 

In contradistinction to the normoblasts, megaloblasts are never 
found in traumatic anaemia, and even in the chronic anaemias of the 
severest grade they are hardly ever seen. Even in leukaemia they 
are usually absent. I have seen a few megaloblasts in a case of 
v. Jaksch's anaemia infantum pseudoleukemia, and. together with 
Dr. Amberg, observed the blood in a case of severe infantile diar- 
rhoea referable to amoebic dysentery, in which a few isolated cells 
of this type were encountered. 

In cancer of the stomach, according to Osier and MeCrae, 1 mega- 
loblasts rarely, if ever, occur. 

In pernicious anaemia, even in the early stages of the disease, 
megaloblasts are quite constantly present, although they are usually 
not numerous. As they are found normally only in foetal bone- 
marrow. Ehrlich views their presence in the blood as a symptom of 
retrogressive metamorphosis, and of grave prognostic import. The 
only exception to this general rule is that form of pernicious anaemia 
which at times is observed in association with the presence of both- 

1 Osier and McCrae. X. Y. Med. Jour.. May 19. 1900. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 69 

riocephali in the intestinal tract. In one case of this kind, reported 
by Askanazy, 1 the megaloblastic type of blood regeneration dis- 
appeared after expulsion of the parasites — sixty-seven in number, 
— and was replaced by the normoblastic type, the case ending in re- 
covery. From this observation Askanazy concluded that a material 
difference does noi exist between normoblasts and megaloblasts, and 
that the t'ormer develop from the latter. lint, as Ehrlich 2 maintains, 
it is certainly more likely that the megaloblastic degeneration of the 
bone-marrow is referable directly to the action of certain toxins, 
and that such a relation between the normoblasts and megaloblasts, 
as Askanazy assumes, does not exist. 

3. MJCROBLASTS. — These are unusually small nucleated red cor- 
puscles, and only rarely observed. They have been found in cases 
of traumatic anaemia, but have attracted little attention. 

The Leucocytes. 

The leucocytes, or white corpuscles of the blood, as seen in freshly 
prepared specimens, are roundish or irregularly shaped cells, and 
mostly larger than the red corpuscles. They are nucleated, and 
many are distinctly granular in appearance, so much so, in fact, that 
the nuclei are often hidden from view (Plate II., Fig. 1, A). In a 
carefully spread specimen some leucocytes will be met with which 
are endowed with the power of locomotion, creeping over the field of 
vision by throwing out pseudopodia in a manner analogous to that 
seen in ameebaB. In their general mode of living the motile leuco- 
cytes, moreover, closely resemble amcebse, and it is most interesting 
to observe the manner in which these little bodies take up cellular 
debris, and even obnoxious organisms that may be present in the blood. 
In malarial blood, for example, in which, as will be shown later, cer- 
tain amoebic parasites are present, one is frequently able to observe 
leucocytes approach these bodies and take them up into their interior 
(Fig. 15). Metschnikoif regards this function of the leucocytes as 
their most important one. Those leucocytes which possess this 
power of removing foreign matter from the blood he has termed 
phagocytes, and, according to his views, the outcome of a bacterial 
invasion, figuratively speaking, will depend upon the superiority of 
the organisms engaged in warfare. The term /)Juir/ocj,tosis has been 
applied to the destruction of micro-organisms by leucocytes. 

General Differentiation of the Various Forms of Leucocytes. 
— Upon ordinary microscopical examination three varieties of leuco- 
cyte- can be distinguished (Plate II., Fig. 1, A). Some arc round, 
smaller than the red corpuscles, and provided with a large round 
nucleus, which is surrounded with a very narrow rim of non-granular 

1 Askanazy, "Ueber Bothriocephalus-Anaemie," etc., Zeit. f. kiln. Med.. 1895. vol. 
xxvii. 

2 Ehrlich, Die Anaemie, p. 43. 



70 



THE BLOOD. 



protoplasm. Others are met with which are likewise round, of the 
size of an ordinary red corpuscle or somewhat larger, and contain a 
large single nucleus which is surrounded by a wider zone of non- 
granular protoplasm. The largest cells, the bodies of which are 
filled with granular material, often hiding the nucleus from view, 
are representatives of the third variety. 

Fig. 15. 




Phagocytosis. 



Upon further examination differences may also be demonstrated 
in the character of the granulations. Some leucocytes will thus be 
observed in which they are very fine, giving the entire body of the 
cell a somewhat cloudy appearance, and usually obscuring the 
nucleus. This may be brought into view, however, by treating the 
preparation with a drop or two of a 1 per cent, solution of acetic 
acid. On the other hand, very coarse granulations may be observed 
in certain leucocytes, while still others, as already pointed out, are 
apparently non -granular. 

Ehrlich, 1 in studying these various granulations in their behavior 

1 Ehrlich divides the acid dyes derived from coal-tar into two large groups — i. e., into 
dyes which color certain granulations even when employed in concentrated solutions 
of glycerin, and into those which can he employed only in aqueous solutions. 

The first group comprises : 

(1) The highly acid bodies belonging to the fluorescin series, viz., eosin, methyl- 
eosin, erythrosin, coccin, pyrosin J and E ; (2; the highly acid nitro-bodies, such as 



PLATE V. 














Note the size of the various leucocytes, as compared with the red corpuscles at 15. Figs. 
1, 2 and 6 represent the most common forms of the small type of lymphocytes ; 3 and 5 belong 
to the same group, but are manifestly atypical ; 3 shows the knob-like projections, described 
in the text ; 4 represents the large type of the lymphocyte, and shows the vacuolated appear- 
ance of the protoplasm, which is so commonly seen. The metachromatism of the protoplasm, 
however, does not appear here as in nature. 7 and 8 are representatives of the large variety 
of mononuclear leucocytes; 9 maybe classed as a transition form, which is as yet devoid of gran- 
ules ; 13 represents a neutrophilic myelocyte, 14 an eosinophilic myelocyte. 10 a neutrophilic 
polynuclear leucocyte, 1 1 an eosinophile of the same type, and 12 a typical basophilic leucocyte. 

The preparations were stained with the eosinate of methylenc-blue and drawn to scale. 
Bausch and Lomb, Eye-piece i inch, objective 1-121I1.) 



PLATE VI. 



p fir 







i r 



•• * 




2 V^'W 



.-> 



''•• 5 >-.?7« ; '*' 



^ 






Hie Blc : " : ■:' Lymphatic- Leukaemia. 



Note the large increase of the lymphocytes. Two of the red corpuscles are undergoing granular 
degeneration (i) ; in a few others polychromatophilia (2) can be discerned; at 3 an eosino- 
philic leucocyte is seen with scattered grounds. (Bausch and Lomb, 
iece 1 inch, objective i-izth.) 



MICROSCOPICAL EXAMINATION OF Till- BLOOD. 71 

toward anilin dyes, found that different chemical affinities exist be- 
tween these minute particles of protoplasm and the reagents em- 
ployed. Some arc thus colored only by acid dyes, others again only 
by those of a basic nature, while still others are stained only by 
neutral dyes. These observations are of the greatest importance 
from a clinical standpoint, and have indeed revolutionized the entire 
tield of hematology. 

Differentiation of the Leucocytes according to their Behavior 
toward the Anilin Dyes. — According to their behavior toward the 
anilin dyes, Ehrlich 1 has divided the granular leucocytes of the 
blood into eosinophilic or oxyphilic, basophilic, and neutrophilic 
leucocytes. In this manner the following forms can be distinguished 
(Plate II., Fig. 2 ; Plates III, IV, V, and VI.) : 

1. Small Mononucleae Leucocytes. — These are mostly 
smaller than the red corpuscles or of equal size. They are devoid 
of granular matter, each cell being provided with a large, homo- 
geneous and uniformly staining nucleus, which is surrounded by a 
narrow rim of protoplasm. In the larger forms, especially, a faint 
areola may sometimes be seen between the nucleus and the proto- 
plasm, which is probably owing to artificial retraction. Nucleus 
and protoplasm both are basophilic, but with certain dyes the 
protoplasm is colored much more deeply than the nucleus. Within 
the uucleus one or two nucleoli may sometimes be seen. The pe- 
riphery of the larger forms is usually shaggy in appearance, and it 
is not uncommon to find particles of protoplasm in the circulating 
blood which have manifestly separated from this peripheral margin. 
In stained specimens the origin of these particles may be recognized 
from their color, which coincides with that of the parent-corpuscles. 
As the protoplasm of the small mononuclear leucocytes has no affinity 
for acid or neutral dyes, these elements appear merely as faintly 
stained, apparently free nuclei in specimens which have been colored 
with the tri-acid stain (see page 100). The reaction of the proto- 
plasm, as shown with the erythrosin method, is strongly alkaline. 
It contains no glycogen. At times an invagination of the nucleus 
may be observed, indicating beginning division of the cell. The 
nuclear figures which result, however, differ materially from those 
seen in the true polynuclear elements. Stained with methylene-blue 
or the eosinate of methylene-blue, the protoplasm often appears 

aurantia: (3) the two groups of sulpho-acids — i. e., indulin, bengalin. and nigrosin, on 
the one hand, and the azo-stains, tropaeolin, Bordeaux, and Ponceau, on the other. 

Tin- second group comprises: 

(1) Fluorescin and chrysolin; (2) ammonium picrate and naphthylamin-yellow ; 
(3) orange and true yellow. 

Representatives of the basic stains are: fuehsin (rosanilin ). the methyl derivatives 
of rosanilin, viz.. methyl-violet, methyl -green, etc., the phenyl derivatives of rosanilin, 
rosonaphthylamin, cyanin, safranin, etc. 

As an example of a neutral stain may he mentioned the picrate of rosanilin. 
1 Ehrlich. Farbenanalytische Untersuchungen z. Histologie u. Klinik d. Blutes, 
Berlin, 1891. 



72 THE BLOOD. 

coarsely granular. This appearance, however, is not due to the 
presence of free protoplasmic granules, but to nodal thickenings 
of the reticulum. Similar appearances are seen in the nucleus. 
AVith Ehrlich's stain, on the other hand, both nucleus and proto- 
plasm appear perfectly homogeneous. Abnormally large forms are 
notably seen in lymphatic leukaemia, but occur also in normal 
blood. Ehrlich states that it is scarcely likely that their true 
nature will be overlooked, if the characteristics just described are 
borne in mind. I must confess, however, that the differentiation 
of these large lymphocytes from the large mononuclear leuco- 
cytes proper is not always an easy matter, and I have often been 
puzzled to classify properly cells of this type. In typical speci- 
mens, in which the protoplasm is stained intensely by the basic 
component of the eosinate of methylene-blue, and in which an 
apparent vacuolization of the entire protoplasmic portion of the 
cell is not uncommonly seen, there is, of course, no difficulty ; but 
there are others in which these characteristics are not so apparent, 
and then the protoplasm and nucleus are both about evenly and 
imperfectly stained. These forms, I think, may readily be con- 
founded with the large mononuclear elements proper, and possibly 
represent transition -forms between the two groups of cells. Together 
with Dr. Amberg, I observed the blood, of a very anaemic child in 
which the condition was apparently secondary to a protracted attack 
of amoebic dysentery, and in which the large lymphocytes, as they 
are perhaps best termed, were quite numerous. But in adults also 
I have usually seen representatives of this group, even under normal 
conditions, where the eosinate of methylene-blue was used as a stain. 
With this dye the protoplasm commonly stains metachromatically, 
and in this respect they differ from the small variety. Ortho- 
chrornatism, however, also occurs (see Plate V.). 

As the small mononuclear leucocytes are formed practically only 
in the lymph-glands, they have been termed lymphogenic leucocytes 
or lymphocytes. 

Under normal conditions the lymphocytes constitute from 22 to 
25 per cent, of the total number of the leucocytes. At birth, 
however, from 50 to 60 per cent, of the total number belong to 
this order ; larger numbers are met with also during childhood than 
in adults, and "the normal proportion is usually not reached before 
the fourteenth year. 

Under pathological conditions the greatest absolute as well as rela- 
tive increase is observed in cases of lymphatic leukaemia. A relative 
increase alone occurs in healthy infants, in various diseases of infancy, 
notably those affecting the gastro-intestinal tract, in chlorosis, per- 
nicious anaemia, secondary syphilis, in the late stages of typhoid 
fever, in certain cases of Basedow's disease, haemophilia, goitre, etc. 
(see also page 93). 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 73 

2. Large Mononucleae Leucocytes. — These arefrom two to 
three times as Large as the red corpuscles, and provided with a large 
single nucleus, which is oval or elliptical in form and surrounded by 
a wide /one of non-granular protoplasm. In specimens stained 
with the fcri-acid stain beginners arc very apt to overlook this form, 
as the nucleus and particularly the protoplasm are often very faintly 
stained. The nucleus and protoplasm are both basophilic, hut the 
latter, in contradistinction to the protoplasm of the lymphocytes, less 
so than the nucleus. In these cells also the protoplasm and nucleus 
do not appear perfectly homogeneous when stained with methylene- 
blue or the eosinate of methylene-blue, hut show evidence of the 
existence of a reticulum which is coarser in the nucleus than in the 
protoplasm (Plate \\). 

These forms are by some thought to represent a later stage in the 
development of the small mononuclear variety, but Ehrlich x still 
maintains their independent origin from the bone-marrow, and to 
some extent perhaps also from the spleen. 

They occur in increased numbers in cases of chronic malaria, in 
measles, in the late stages of scarlet fever, and in many of the diseases 
in which the small mononuclear elements are increased. I have met 
with a considerable relative increase of this variety in one case of 
Addison's disease shortly before death. In one of my patients, a 
woman aged sixty-three, attention first was directed to the existence 
of a large sloughing epithelioma of the neck by the discovery of 
21 per cent, of the large mononuclear leucocytes. 

Under normal conditions the percentage varies between 1 and 2. 

3. Transition-forms. — These develop directly from the large 
mononuclear leucocytes. They are still mononuclear, but the 
nucleus is greatly invaginated, indicating approaching division. 
A- a general rule, no granules are observed, but at times they do 
occur, when they are neutrophilic in character. In specimens 
stained with the tri-acid stain the nucleus is colored somewhat 
deeper than in the second variety. 

Together with the lari^e mononuclear elements they constitute 
from 2 to 4 per cent, of the total number of leucocytes. 

4. The Neutrophilic Polyxuceear Leucocytes. — These 
cells are a little smaller than the large mononuclear leucocytes and the 
transition-form-, and are tilled with very line neutrophilic granules, 
the s-granulation of Ehrlich. The protoplasm itself is finely re- 
ticulated, but this is generally overlooked unless the specimen is 
especially stained with methylene-blue or a similar stain. The nucleus 
is a long body, which is twisted upon itself into irregular forms, some- 
times resembling the letters S, Y, E, Z. At other times it presents 
a broken appearance, conveying the impression that several nuclei 
are present. Hence their original name — polynuclear leucocytes. As 

1 Ehrlich. Die Anaemie, p. 49. 



74 THE BLOOD. 

Ehrlich has suggested, however, the poly nuclear appearance is prob- 
ably referable to post-mortem changes, the condition of the nucleus 
being in reality polymorphous. In accordance with this view, thev 
are hence also spoken of as polymorphonuclear neutrophilic leu- 
cocytes. The nucleus stains readily with all nuclear dves, while the 
protoplasm shows a marked affinity for the greater number of acid 
dyes. Its reaction, as tested with acid erythrosin, is alkaline, but 
less so than the protoplasm of the lymphocytes. In health a glvco- 
gen reaction is not obtained. The nucleus is coarsely reticulated, 
and generally shows evidence of a central nodal thickening in its 
lobes. 

According to some observers, the polymorphonuclear neutrophilic 
leucocytes represent a later stage in the development of the small 
and large mononuclear cells. Ehrlich, 1 however, insists that the 
greater number enter the blood from the bone-marrow, where thev 
develop from the mononuclear neutrophilic leucocytes — the myelo- 
cytes — or bone-marrow cells proper (see page 78), but he admits that 
a small number may be derived directly from the transitional forms 
in the blood-current. 

In this connection it is especially interesting to note that while 
basophilic and oxyphilic granules are found in the blood of all ver- 
tebrate animals, the neutrophilic granulation occurs only in man 
and the ape. 

Of late, a diminution in the number of the neutrophilic granules 
has attracted some attention in association with the acute hyperleu- 
cocytoses. Ewing 2 states that this abnormality may progress till 
very few granules are left, while their complete absence is seen 
principally in chronic leukaemia. He adds that this phenomenon 
is associated usually with marked nuclear changes of a degenerative 
character, which he describes as follows : in fresh or dry specimens 
the nuclei stain less densely with basic dyes, their outlines are 
irregular, and the lobes shrunken. The degeneration may follow 
the type of karyolysis with swelling and loss of chromatin, or of 
karvorrhexis with hyperchromatosis and subdivision of lobes. 
In acute leucocytosis the former type is more usual, but in leukae- 
mia the latter form is seen abundantly. "While the lobes of the 
normal polynuelear leucocytes are almost invariably connected by a 
thread of chromatin, many of the cells in severe acute leucocytosis 
show complete subdivision of the nucleus into three to six separate 
segments. This fragmentation of the nucleus was noted first by 
Ehrlich in a case of hemorrhagic smallpox, and is of frequent occur- 
rence in fresh exudates. I have observed the same together with Dr. 
Amberg in a case of infantile anaemia associated with amoebic dys- 
entery, in which extensive hyperleucocytosis, however, did not exist. 
The loss of neutrophilic granules in the polymorphonuclear leuco- 

1 Ehrlich, loc. cit., p. 71. 2 Ewing, loc. cit., p. 113. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 75 

cytes in cases of chronic leukaemia is sometimes most striking, and 

1 was much interested to note in a recent case that while the poly- 
nuclear elements were mostly devoid of granules, the neutrophilic 
myelocytes (see below) were quite normal in appearance. In other 
diseases deficiency of granules is in my experience not necessarily 
associated with acute hyperleucocytosis, hut may occur under the 
most diverse' conditions, which as yet admit of no classification. 

Normally the polynuclear neutrophilic leucocytes constitute from 
70 to 72 per cent, of all leucocytes. 

The most common forms of hyperleucocytosis are referable to 
an increase in the number of these elements (see page 81). All 
pus-corpuscles, moreover, according to Ehrlich, belong to this 
class. 

5. The Oxyphilic or Eosinophilic Leucocytes. — In size 
and general appearance these cells resemble the polynuclear neutro- 
philic leucocytes. But they differ from these in the absence of neu- 
trophilic granules, and the presence, instead, of large ovoid or 
roundish, highly refractive, fat-like granules — the ^-granulation of 
Ehrlich. These granules are stained only with acid dyes, such as 
eosin and acid fuchsin, and such leucocytes have hence been termed 
oxyphilic or eosinophilic leucocytes. Barker, 1 moreover, has shown 
that these granules contain iron. Like the polynuclear neutrophilic 
leucocytes, they are also phagocytic. The nucleus is usually bilobed 
and coarsely reticulated. 

According to some observers, the eosinophilic leucocytes represent 
the senile stage in the development of the small mononuclear leuco- 
cytes. But Ehrlich still regards them as independent bodies formed 
in the bone-marrow from mononuclear eosinophilic cells, analogous 
to the formation of the polynuclear neutrophilic leucocytes from the 
mononuclear neutrophilic cells. 

Normally the percentage of eosinophilic leucoevtes varies between 

2 and 4. 

An absolute increase in their number is observed in all uncompli- 
cated cases of myelogenous leukaemia, while a relative increase is 
inconstant. Statements to the contrary have been made by many 
observers, but, a^ Ehrlich suggests, this is undoubtedly owing to a 
confusion between the terms absolute and relative. According to 
Zappert, 2 50 to 100 eosinophilic leucocytes in the cbmm. of blond 
should be regarded as the lowest normal values, 100 to 200 as the 
average, and 200 to 250 as the highest normal figures. Supposing 
then that in a given case the percentage of eosinophils is 3.5 ; 
this would, of course, be a perfectly normal percentage. But if 
at the same time the total number of leucoevtes is 400,000, it is 
apparent at once that we are dealing with a considerable absolute 

1 L. V. Barker. Johns Hopkins Hosp. Hull.. 1894, p. !»:!. 

2 J. Zappert. "Ueberd. Vorkommen d. eosinophilen Zellen im anaemischen Blut," 
Zeit. f. klin. Med., vol. xxiii. 



THE BLOOD. 

increase ^responding in this k - 14. 000 eosinophilic leucocytes 
— i. e„, an increase of fifty-six times the maximum number observed 
under normal conditions. It may be stated as a general rule that 
whenever : j.te increase in the number of the eosinophilic leueo- 

i not found in : :f supposed myelogenous leukaemia this 

diagnosis may be abandoned, providing that complications, such 
as septic pre sesses do not exist at the same time. In sepsis 
the num : : eosinophilic leucocytes is materially diminished, 
and in some cases they may be altogether absent. Exceptions, 
however, occur, and Ehrlich cites a ease in which the total number 

- still from 1400 to 1500 in the cbmm., although the percentage 
had diminished from 3.5 to 0.43. 

A - . le from myelogenous leukaemia, an increase in the number of 
the eosinophilic leucocytes has been observed in various other dis- 
eases : but it is scarcely likely that any of these would be mistaken 
for leukaemia, especially if the other blood-changes which occur in 
this disease are borne in mir - P&ge 89). Eosinophilia has 
thus been noted in bronchial asthma, in certain diseases of the bones, 
the skin, the nervous system, in the helminthiases, in trichinosis, in 
malignant disease, in the post-febrile period of many of the acute 
infectious diseases, in gonorrhoea, etc. In diminished numbers the 

sinophilie ?ells are found during the process of digestion, in pneu- 
monia, in the course of most of the acute infectious diseases, follow- 
ing castration, ete sec lis Eosinophil] 

6. Basophilic Leucocytes. — In normal blood these rarely exceed 
per cent, of the total number of leucocytes. The size of the cells 
varies from 3.5 a to 14 ti in diameter. They are usually rounded or 
oval, but may also be oblong, and may then have a length of 22 a. 
The cell substance is dear and homogeneous, but imbedded within 
there are granules, the y- and a-granulations of Ehrlich, which ap- 
pear to be identical with those observed in the so-called ma.st-eells, 
found in connective tissue especially. The same term has hence 
been applied to this variety in the blood. The individual granules 
vary somewhat in size and distribution, and are characterized by 
their affinity for basic dyes. They do not take on a pure color, 
however, but stain metachromatieally. With cresyl-violet R, for 
example, they are colored almost a pure brown, and with eosinate of 
methylene-blue they take on a violet color. The nucleus is stained 
with great difficulty. It is lobulated, and almost always placed 
ex centric-ally. It i- oval or rounded, and has an almost uniform 
diameter £ "When the cell itself is of a less diameter, the 

nucleus comprises almost the entire cell and is covered by only a 
very thin layer of granules. In specimens stained with carbol- 
toluidin-blue, and differentiated with glycerin-ether, the granules 
appear dark red in color, while the nucleus is colored blue. In 
bn ns rained with the tri-acid stain the granules are colorless, 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 11 

and the cells hence appear as light polymorphonuclear formations, 

which are apparently devoid of granulations. According to Harris, 1 
the granules arc composed of mucin, and the cells elaborate the 
mucin of the connective tissue. Ehrlich supposed that the mast- 
cells originated from the connective-tissue cells as a result of hyper- 
nutrition, but it is more likely, as Harris suggests, that they are 
derived from the large mononuclear leucocytes. 

Aa increase in the number of mast-cells is almost exclusively 
observed in myelogenous leukaemia, and is hence of great diagnostic 
importance. This increase is constant and absolute, and may even 
exceed the increase of the eosinophilic leucocytes. 

Ewing 2 states that he constantly failed to find mast-cells in the 
better class of healthy subjects, while in hospital and dispensary 
cases with minor ailments they appeared to be more numerous. 
Formerly I also found mast-cells only exceptionally, but since I 
have used the eosinate of methylene-blue as a matter of routine in 
my laboratory I rarely meet with specimens of blood, no matter 
from what class of patients, in which they are absent. 

Neusser's Perinuclear Basophilic Granules. — A few years ago 
Neusser 3 drew attention to the fact that basophilic granules are not 
infrequently seen arranged about the nuclei of the mononuclear and 
polynuclear leucocytes. The presence of these granules he, as well 
as Kolisch, 4 regarded as characteristic of the so-called uric acid diath- 
esis. As tubercular disease, moreover, is usually not seen in such 
cases, Neusser regards their presence in cases of phthisis as a 
favorable symptom. Futcher, 5 on the other hand, was unable to 
confirm these conclusions, and my own observations likewise are 
opposed to those of Neusser. I was able to demonstrate the pres- 
ence of these granules both in health and disease in almost every 
case, and was even led to the conclusion that their absence in a sup- 
posedly healthy individual may be regarded as presumptive evidence 
of the existence of some morbid process. Whether this conclusion 
will be borne out by further investigations remains to be seen. But 
it appears to be certain that in malignant disease the granules are 
either absent or present in greatly diminished numbers. In two 
cases of gastric ulcer and in one of acute gonorrhoea, however, I 
was likewise unable to find them. 6 

In suitably stained specimens the granules appear as greenish- 
black or entirely black little dots, which are irregularly scattered 
over the surface of the nucleus. Their size varies considerably. 
Specimens are thus encountered in which the granules are as fine as 

1 H. T. Harris, " Histology and Microchemic Reactions of Some Cells to Anilin 
Dyes," Phila. Med. Jour., 1900, p. 757. 

2 Ewing, On the Blood, Lea Bros., Phila., 1901, p. 143. 

3 Neusser, Wien. klin. Woch., 1894, p. 71. 4 Kolisch, Ibid., 1895, p. 797. 

5 Futcher, Johns Hopkins Hosp. Bull., May, 1897. 

6 C. E. Simon, " On the Presence of Neusser's Perinuclear Basophilic Granules in the 
Blood," Am. Jour. Med. Sci., vol. cxvii. p. 139. 



78 THE BLOOD. 

ordinary neutrophilic granules, while in others they are much larger, 
and in some cases droplets may be seen which cover nearly the 
entire nucleus. They may be found in all forms of leucocvtes 
described, but are most numerous in the polymorphonuclear and 
small mononuclear cells. 

Ehrlich has expressed the view that these granules are arte- 
facts, and states that they are observed only exceptionally when 
strictly pure solutions, made from the crystalline dyes of the Actien- 
gesellschaft fur AnilinfarbstofTe in Berlin, are used. Whether this 
view is correct I am not prepared to say, as my examinations 
were made with the Griibler stains. A relation between their 
presence and the elimination of uric acid or xanthin-bases does not 
exist. 

7. ^Neutrophilic Myelocytes. — These are essentially large 
mononuclear leucocytes, the protoplasm of which contains more or 
less numerous neutrophilic granules. Their size, however, is subject 
to considerable variation. On the one hand, they may be larger than 
all other elements of the blood — the so-called myelocytes of Cornil ; 
while others are observed which are scarcely larger than an ordinary 
red corpuscle — the so-called myelocytes of Ehrlich. The nucleus is 
large, usually centrally located, and possesses only a feeble affinitv 
for dyes. Unlike the polynuclear neutrophilic leucocytes, they are 
never amoeboid. 

According to the school which regards the polynuclear neutro- 
philic leucocytes as the mature forms of the lymphocytes, the 
neutrophilic myelocytes represent an arrested or perverted form 
of development of the large mononuclear cells. Ehrlich, on the 
other hand, regards the neutrophilic myelocyte as the bone marrow- 
cell proper, and as the young form of the polynuclear neutrophilic 
leucocyte. 

Under normal conditions they are never found in the blood, and 
Ehrlich teaches that their presence in considerable numbers may be 
regarded as indicating the existence of myelogenous leukaemia. In 
smaller numbers they have been found in a case of lymphosarcoma 
with metastases in the bone-marrow ; further, in severe post-hemor- 
rhagic anaemia, in a case of poisoning with mercury, in the pseudo- 
leukaemia of infants, in torpid scrofula, and, what is especially im- 
portant, in some of the acute infectious diseases. Engel l thus found 
that in diphtheria occurring in children myelocytes can often be 
demonstrated in the blood, and that a high percentage, viz., 3.6 to 
16.4, of the total leucocytes is observed only in severe cases, and ren- 
ders the prognosis unfavorable. In mild cases they are not often 
seen, and when present occur only in small numbers. In pneumonia 
myelocytes are either absent or present only in small numbers at 
the beginning of the disease, while at the time of the crisis or imme- 

1 Engel. Deutsch. med. Woch.. 1897, vol. xxiii. No. 8. 




MICROSCOPICAL EXAMINATION OF THE BLOOD. 1\) 

diately thereafter they become more numerous, and in some cases 
may Dumber L2 per cent, of all neutrophilic cells. 

Small numbers of myelocytes may further be seen in the various 
anaemias from whatever cause. They have been noted in pernicious 
ansemia, in the ansemia of syphilis, and, as I have stated, in the 
pseudoleukemia of v. Jaksch, in association with malignant growths, 
etc. In the child, already referred to, in which a notable ansemia 
developed as the result of amoebic dysentery, Dr. Amberg counted {) 
per cent. Neusser also records the presence of neutrophilic myelo- 
cytes in anaemia, asphyxia, acute mania, etc. ; and Ewing states that 
they have been found in considerable numbers in rickets, osteomyelitis, 
and osteomalacia. 

8. Eosinophilic Myelocytes. — These represent the eosino- 
philic homologue of the form just described. Their size also may 
vary very much, and specimens may be met with which are a great 
deal larger than the poly nuclear variety. According to Ehrlich, they 
are likewise formed in the bone-marrow, and represent an earlier 
stage in the development of the polynuclear eosinophilic leucocyte. 
Their presence is confined largely to the blood of myelogenous leu- 
kemia and the pseudoleukemia of infants. Mendel l found them 
in one case of myxoedema, Turck 2 reports that they are occasionally 
seen in some of the infectious diseases, and Bignami claims to have 
seen them in pernicious malaria. 

9. Small Neutrophilic Pseudolymphocytes. — These bodies, 
according to Ehrlich, are produced by direct division of the poly- 
nuclear neutrophilic leucocytes. They are about as large as the small 
lymphocytes, and provided with a single deeply staining nucleus. 
The narrow zone of protoplasm which surrounds the nucleus con- 
tains neutrophilic granules. They may be distinguished from the 
small forms of myelocytes by the greater intensity with which the 
nucleus takes up the nuclear dyes and the smaller amount of proto- 
plasm. Ehrlich 3 states that he first saw these bodies in a case of 
hemorrhagic smallpox, but that they are found also in recent pleural 
effusions. He suggests that their study may be of importance in 
deciding the origin of the transitory hyperleucocytoses, which ac- 
cording to some are due to a destruction of leucocytes, and accord- 
ing to others to an altered distribution. 

10. Irritation-forms. — These are mononuclear, non-granular 
cells, the protoplasm of which is stained a rich brown by the tri- 
acid mixture. The nucleus is round, often excentrically located, 
and colored a bluish green. The smallest forms are somewhat 
larger than the lymphocytes. According to Turck, 4 who first de- 

1 K. Mendel, " Ein Fall von mvxtedematosem Cretinismus," Berlin, klin. Woch., 
189f>, No. 45. 

1 Turck, Klinische Untersuchungen fiber d. Verhalten d. Blutes bei akuten Infec- 
tionskrankhriten. Wicii u. Leipzig. 1898. 

3 Ehrlich, Die Auaemie, loc. cit. 4 Loc. cit. 



80 THE BLOOD. 

scribed these cells, they are met Avith under the same conditions as 
the myelocytes. Possibly they represent an early stage in the 
development of the nucleated red corpuscles. 

In addition to the above, still other forms of leucocytes have 
been described, especially in leuksemic blood, but so little is known 
of these that it is unnecessary to enter into their description at this 
place. 

Variations in the Number of the Leucocytes. — While the 
number of red corpuscles is subject to very slight variations under 
physiological conditions, that of the leucocytes varies within fairly 
w T ide limits, being influenced by the age and sex of the individual, 
pregnancy, the process of digestion, the bloodvessel from which the 
specimen is taken, etc. 

According to Osier, the number of leucocytes per cbmm. of 
blood, obtained from the finger or the ear, normally varies between 
5000 and 7000, so that taking 5,000,000 as the average number of 
red corpuscles per cbmm., the ratio between the two would vary 
between 1 : 714 and 1 : 1000. Bat, as Cabot points out, the actual 
number may be still lower than 5000 and higher than 7000 without 
there being symptoms of definite illness. Generally speaking, lower 
figures are met w T ith in persons who are somewhat ill-nourished, 
while higher figures are encountered in persons of special vigor 
and good nutrition. Before concluding then that in a given case 
the number of leucocytes is below or above the normal, an idea 
should, if possible, be formed of what constitutes the normal for 
that particular individual. It would hence be better to extend 
the normal limits to 3000 on the one hand, and 10,000 on the 
other. 

An increase in the number of leucocytes, to which condition the 
term leucocytosis was first applied by Yirchow, is met with under 
both phvsiological and pathological conditions. As Goldscheider 
rightly suggests, it would be better, however, to restrict the term 
leucocytosis to indicate the number of leucocytes in a general way, 
and to speak of an increase in their number as hyperleucocytosis, and 
of a diminution in their number as hypoleucocytosis. According to 
Ehrlich, furthermore, it is necessary to distinguish between active 
and passive hyperleucocytosis, meaning by active hyperleucocytosis 
that form in which the increase in the number of the leucocytes 
principally affects the phagocytic elements, viz., the poly nuclear 
leucocytes, while the mononuclear elements only are increased in 
the passive form. 

Ehrlich further subdivides the active hyperleucocytoses into the 
following groups : 

1. The polynuclear hyperleucocytoses. 

a. Polynuclear neutrophilic hyperleucocytosis. 

b. Polynuclear eosinophilic hyperleucocytosis. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 81 

2. The mixed hyperleucocytoses in which the granule-bearing 
mononuclear elements take part — myelsemia. 

Polynuclear Neutrophilic Hyperleucocytosis. — In this form 
of hyperleucocytosis, as the term indicates, the increase in the num- 
ber of the leucocytes principally affects the polynuclear neutrophilic 
elements. Exceptionally it may be associated with a polynuclear 
eosinophilic hyperleucocytosis, as well as with a lymphocytosis, but 
as a general rule both eosinophilic leucocytes and lymphocytes are 
much diminished. This diminution, moreover, may not only be 
relative, but even absolute. 

Under this heading the following forms may be considered : 

Physiological Hyperleucocytosis. — An increase in the number of leu- 
cocytes, occurring in health, is noted during the process of digestion, 
in pregnancy, following cold baths, after severe muscular exercise, etc. 

In infancy also a hyperleucocytosis is observed quite constantly, 
and, according to Hay em, 1 is most pronounced during the first eighty 
hours of life, when about 18,000 leucocytes are found on an aver- 
age in the cbnini. of blood. This number, however, soon dimin- 
ishes, and during the first month about 8000 leucocytes may be 
regarded as the normal. In children aged from several months up 
to the first year this figure further drops to about 6000. Owing to 
the intensity with which the blood of infants generally reacts to all 
manner of stimuli, however, it is difficult to set down definite fig- 
ures to express the normal. It is thus not uncommon to observe a 
hyperleucocytosis corresponding to the first months of life even as 
late as the first and second year in feebly developed children, but 
which in other respects may be quite healthy. The process of diges- 
tion, moreover, as will be shown later, very materially influences the 
degree of leucocytosis, so that at this time of life one should be 
very careful in drawing inferences from the blood-count alone as to 
the existence of disease. 

Associated with an absolute increase in the number of the poly- 
nuclear neutrophilic leucocytes we find in the leucocytoses of infants 
quite constantly also a relative lymphocytosis. 

An idea of the marked increase in the number of the leucocytes 
occurring during the process of digestion, constituting the physio- 
logical digestive leucocytcsis of Virchow, may be formed from the 
accompanying diagram (Fig. 16). It is especially pronounced after 
a preliminary period of fasting, and following a meal rich in proteids. 
Occasionally it is not seen, even in health, but such cases are ex- 
ceptional. In infants the highest grades are observed, and Cabot 
cites a case, reported by Schiff, 2 in which 19,500 leucocytes were 
counted one hour after birth, 27,625 after the first meal, and 36,000 
after the fourth meal. 

1 Havem. Compt. rend, rle la soc. de biol., 1887, p. 270. 

2 Schiff, Zeit. f. Heilk., vol. xi. p. 30, and 1890, p. 1. 



82 



THE BLOOD. 



Under pathological conditions, and notably in gastro-intestinal 
diseases, this form of hyperleueocytosis is frequently absent. This is 
notably the ease in carcinoma, and for a time it was thought that the 
absence of a digestive hyperleueocytosis could be regarded as a valu- 
able symptom in the differential diagnosis between carcinoma and 
other diseases of the stomach. 1 Unfortunately, further investigations 



Mm. 








- 


A.M. 
10 


1 


Fig. 16. 

Bed corpuscles in 1 cbmm. of blood. 

P.M. 

1 2 4 6 8 10 12 2 


- 


A.M. 

r 




8 








P 
























J 1 


5 4 










"""i \ 


































' 






\ ^^ 








A 






















5 ""■ 






/ 


































5,1 












































V 








































































Gms. 
0,140 


Hb. in 1 cbmm. of blood. 
























































0,135 








A 




















X— "j"n 












\ 








0,130 






K 




\ v-\^c ^ 










\ / 






123 




^ / 












i ^f 









Leucocvtes in 1 cbmm. of blood. 







8000 


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Showing tbe diurnal variations in the number of red corpuscles, the amount of hemoglobin, 
and The number of leucocytes. I Taken from Reixeet.) 



have shown that cases of cancer may occur, on the one hand, in 
which digestive hyperleueocytosis does occur, while, on the other, it 
mav be absent in other diseases, both functional and organic. In 

1 J. Schneyer. " Das Verhalten d. VerdauunErsleukoeytose bei ulcus rotunrlum u. car- 
cinoma ventriculi.*' Zeit. f. klin. Med., vol. xxvii. p. 249. E. Miiller, Zeit. f. Heilk., 
1890, p. 213. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 83 

anaemic individuals, from whatever cause, a digestive hyperleucocy- 

tosis may thus not be observed unless an especially large meal has 
been ingested, and in such eases indeed a subnormal number of 
leucocytes may be encountered. 1 The question of digestive hyper- 
leucocytosis is, however, nevertheless a most interesting one and 
calls for further investigation. According to Marchetti, it depends 
essentially upon the digestive and absorptive power of the stomach, 
and it- occurrence or non-occurrence in carcinoma is thus essentially 
an index of the degree of functional impairment of the organ. In 
its study certain precautions must be observed : 

a. The first blood-count should be made after the patient has 
fasted tor about seventeen hours. 

b. After this period he receives a test-meal, consisting of from 200 
to 1000 c.e. of milk, and one or two eggs, the amount varying with 
the condition of the patient. 

c. Further blood-counts are made one, two, and three hours later. 

d. The existence of a digestive hyperleucocytosis should only be 
regarded as proved if an increase of at least 1500 cells occurs, pro- 
viding that maximal amounts of food have been taken. If smaller 
amounts have beeu given, an increase of 100 cells is sufficient to 
establish its existence, provided that the same result is observed on 
repeated examination. 

In the digestive hyperleucocytoses the increase in the number of 
the leucocytes not ouly affects the poly nuclear neutrophilic elements, 
but also the lymphocytes, while the eosinophilic leucocytes are, rela- 
tively at least, much diminished. 

A very marked hyperleucocytosis is also frequently noted after a 
cold bath. According to Thayer, 2 this may amount to even 284.6 
per cent. In twenty cases of typhoid fever he found on an aver- 
age 7724 leucocytes before, and 13,170 after the usual Brand bath. 
In his own person, while in health, on one occasion the leucocytes, 
which numbered 3250 before the bath, rose to 12,500 twenty min- 
ute- later. A prolonged cold bath, on the other hand, diminishes 
their number. Hot baths have exactly the opposite effect, viz., those 
of short duration produce a decrease, those of long duration an 
increase. 

Violent muscular exercise, as w r ell as massage, likewise produces 
a temporary hyperleucocytosis. 

In all these cases the increase affects both lymphocytes and the 
polymorphonuclear leucocytes. 

The physiological hyperleucocytosis observed in pregnancy is par- 
ticularly marked during the last five months, and appears to occur 
quite constantly in primipane, while in multiparas exceptions are 
common. In an analysis of thirty-one cases Rieder 3 noted a hyper- 

1 Rieder. Beitrage zut Kenntnisa d. Leukocytose, 1892. 
2 Thayer. Johns Hopkins Hosp. Bull., April, 1893. 
3 Rieder. loc. cit. 



-4 THE BLOOD. 

leucocytosis in twenty, the number of leucocytes varying between 
X) and 16,000, with an average of 13,000 per cbmrn. This 
increase in the number of the leneoevtes continues for a variable 
period after parturition, and is apparently connected with the function 
of lactation. It is especially interesting to note that a digestive 
hyperleucocytosis does not occur, while that referable to pregnancv 
exists, and it is quite likely, as Cabot l suggests, that this form is in 
reality a prolonged digestive hyperleucocytosis. The increase affects 
both lymphocytes and the poly nuclear neutrophilic leucocytes. 

Pathological Hyperleucocytosis. — In disease an increase in the 
number of the polynuclear neutrophilic leucocytes is observed very 
frequently, and is often a matter of great importance in differential 
diagnosis. 

In the acute infectious diseases hyperleucocytosis is the rule. Gen- 
erally speaking, the increase in the number of the leucocytes is here 
directly proportionate to the intensity of the infection and the power 
of resistance on the part of the individual patient It may thus 
happen that no hyperleucocytosis occurs at all when the infection is 
extremely virulent, and the power of resistance practically nil, in 
consequence of pre-existing disease or similar influences, even though 
the disease is one in which hyperleucocytosis generally occurs. 
This is seen especially well in pneumonia, in which death almost in- 
variably occurs when a hyperleucocytosis does not develop, unless 
indeed the infection has been so mild as not to cause an increased 
invasion of leucocytes. The development of a well-marked hyper- 
leucocytosis in diseases in which this is the rule is no guarantee, 
however, that the patient will recover, although his chances are 
certainly much better. 

In pneumonia the increase in the number of the leucocytes is 
usually marked. According to Cabot. 2 it amounts on an average 
to about 24.000 above the normal. The hyperleucocytosis sets in 
quite earlv and persists until the time of the crisis, when it rapidly 
disappears. When the disease terminates by lysis the return to the 
normal is more gradual. A pseudocrisis is not accompanied by a 
fall in the number of the leucocytes. When resolution is delayed 
or complications occur, the hvperleucocytosis persists. 

In ervsipelas, as in pneumonia, the leucocytosis is generally pro- 
portionate to the intensity of the morbid process, and also terminates 
by crisis. The increase in the number of the leucocytes, according 
to Rieder. 3 amounts to about 15,000 above the normal. 

In diphtheria a well-marked increase is the rule, and, with the ex- 
ception of very mild or extremely severe cases, is of constant occur- 
rence. It is interesting to note that excepting a temporary diminution 
immediatelv after the injection the leucocytosis is in no wise innu- 

*Cabcffc r Clinical Examination of the Blood. Wm. Wood & Co.. 1597. 
* Cabot, loc. cit. 3 Eieder. Die Leukocytose. 1592. 



MICROSCOPICAL EXAMINATION OF THE BLOOD, 85 

enoed by the antitoxin treatment. Besredka, 1 however, states that 
the grade of the polymorphonuclear neutrophilic hyperleucocytosis, 

after the administration of the sennn, indicates the prognosis. Thus, 
it' one or two days after the injection the percentage of these cells 
is GO or above, the prognosis is good ; with a higher temperature 
and 50 per cent., it is bad; while if below 50 per cent., the disease 
is fatal. 

In septic conditions of whatever origin hyperleucocytosis is of 
constant occurrence unless the infection is very mild or very severe. 
As in pneumonia and diphtheria, absence of hyperleucocytosis may 
usually be regarded as a symptom of grave prognostic signifi- 
cance. The degree of increase may vary widely, and is always 
directly proportionate to the extent and the intensity of the inflamma- 
tory reaction. In suspicious eases a careful examination of the blood 
should always be made. It is equally as important in such cases as 
the examination of the sputum in cases of suspected phthisis or of the 
tonsillar coating in cases of suspected diphtheria. 

Especially important also is the study of the leucocytosis in 
appendicitis. In a recent article on blood examination as an aid to 
surgical diagnosis Bloodgood 2 states the following : 

Observed within forty -eight hours the number of white blood-cells 
is in the majority of instances of great value in pointing to the extent 
of the inflammatory condition of and about the appendix. Cases 
of recurrent appendicitis or of appendicitis suffering from the first 
attack, first observed practically at the end of the attack when the 
clinical symptoms are subsiding, rarely show an increase in the 
white cells. In a few instances, first observed within forty-eight 
hours after the beginning of the attack, but when the symptoms 
are subsiding, there have been a few leucocyte-counts of 15,000, 
which have fallen rapidly within a few hours to 10,000 and 7000. 
In the cases admitted within forty-eight hours with acute symptoms, 
if on account of the clinical picture operation has been delayed, a 
falling leucocytosis has always been observed. These patients have 
recovered, and at a later operation the appendix was found to be 
the seat of a diffuse inflammation, but there was no evidence of 
pus outside the appendix. In one case admitted sixteen hours after 
the beginning of the attack the leucocytes fell in ten hours from 
17,000 to 13,000, and in twenty-four hours to 1 1 ,000, associated with 
disappearance of the symptoms. With one exception, the highest 
first leucocyte-count in this group has been 17,000, falling in a few 
hours to 12,000, 9000, or even lower. A patient admitted twenty 
hours after the beginning of the acute attack had a leucocytosis of 
22,000 ; the clinical symptoms, however, were not very marked. 

1 Besredka, Ann. de l'lnst. Pasteur, 1898, vol. xii. 5, p. 305. Cited by T. R. Brown, 
Maryland Med. Jour., April, 1901. 

2 J. C. Bloodgood, " Blood Examinations as an Aid to Surgical Diagnosis," American 
Medicine, 1901, p. 306. 



86 THE BLOOD. 

The patient was observed eight hours ; during this period the leuco- 
cytes fell to 16,000 and the local symptoms practically disappeared. 
Within the next twenty-four hours the leucocytes were 11,000, then 
8000, 7000, and 6000. Although this patient with a leucocytosis 
of 22,000 at the end of twenty hours, recovered, and there is 
every reason to believe that the inflammatory condition about the 
appendix subsided, nevertheless it is an exception to the general rule, 
and it would be safer, I believe, to operate in those cases of acute 
appendicitis observed within the first forty-eight hours with a leuco- 
cytosis of 20,000. 

In acute diffuse appendicitis with operation and recovery the highest 
count observed was 25,000 thirty-six hours after the beginning of 
the attack. At operation in this case intense inflammation and a 
large amount of exudate were found about the appendix. 

In gangrenous appendicitis with operation and recovery the leuco- 
cytosis is higher (25,000-35,000) and rises more rapidly. As Blood- 
good says, the study of the leucocytosis is here of the greatest 
importance in the early recognition of a grave inflammatorv condi- 
tion of the appendix, which without doubt would lead to general 
peritonitis and death unless early operation be instituted. 

A very high leucocytosis within forty-eight hours after the 
beginning of the attack is suggestive, but not at all positive, of 
beginning peritonitis. The leucocyte-count, however, does not seem 
to help in such cases with regard to prognosis. After the second 
day in cases in which the peritonitis has been present longer Blood- 
good never has observed recovery with a low leucocyte-count. 
If the leucocytosis remains still high at this period, however, the 
prognosis seems better for ultimate recovery after operation. . 

In intestinal obstruction an increase of the leucocytes associated 
even with very slight symptoms is of the highest importance in the 
early recognition of the lesion. Bloodgood states that in a large 
group of cases the leucocyte-count may rise to 20,000 within 
twelve hours after the beginning of the obstruction. Within the 
first twelve to twenty -four hours a few observations would demonstrate 
that if the leucocyte-count rise above 25,000 or 30,000, the proba- 
bilities are that one will find gangrene of the obstructed loops or 
beginning peritonitis. If observed on the second or third day 
after the beginning of the symptoms, it is difficult to make a differ- 
ential diagnosis with regard to gangrene or peritonitis. After the 
third day, in cases in which there is no gangrene, and no peritonitis, 
or in which the auto-intoxication is not yet very grave, the 
leucocytes still remain high — 15,000-23,000 — according to the de- 
gree of obstruction : complete, higher ; partial, lower. In the presence 
of gangrene-peritonitis or grave auto-infection, the leucocytes begin 
to fall. If the patient is admitted after the third or fourth day, 
with a history of intestinal obstruction, and still has a high leuco- 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 

cyte-count, the prognosis is good for operation. If the count is 
low, and especially it' it is below 10, 000, the probabilities are that 
on operation extensive gangrene-peritonitis will be found ; or the 
patient will be so depressed by auto-intoxication that reaction d<H>> 
not follow relief of the obstruction. 

In acute articular rheumatism the degree of hyperleucocytosia is 
proportionate to the severity of the attack. The average increase 
beyond the normal, according to Cabot, amounts to about 16,800 
ceils. 

In scarlatina an increase in the number of the leucocytes may be 
observed as early as the sixth day before the appearance of the rash. 
The maximum, an increase of from 10,000 to 25,000 beyond the 
normal, is noted usually on the second or third day after the appear- 
ance of the eruption. The hyperleucocytosis persists for from 
twenty to thirty days. 1 

In smallpox a hyperleucocytosis is observed only in the severer 
cases, and at a time when pustulation takes place. Iu the milder 
forms no increase occurs. 

In tubercular affections hyperleucocytosis is observed only when 
secondary infection with pus-organisms has taken place, while in 
pure cases the number remains normal. But as the chances for a 
secondary infection are more favorable in some parts of the body 
than in others, such as the lungs and kidneys, hyperleucocytosis is 
commonly present when these parts are involved. 

In Malta fever a marked increase in the polymorphonuclear leu- 
cocytes may occur just before the onset of the fever. In a case 
observed in the United States by Musser and Sailer, 2 11,564 leuco- 
cytes were counted, all varieties, however, being in normal pro- 
portion. 

It is thus seen that a hyperleucocytosis of greater or less degree 
occurs in the majority of the infectious diseases, and may be re- 
garded as the rule. There are, however, a number of very inter- 
esting and important exceptions. In uncomplicated cases of typhoid 
fever and in measles no hyperleucocytosis ocera-s, and the number of 
the leucocytes may indeed be diminished. The importance of this 
fact from the standpoint of differential diagnosis is self-evident. 

As regards the other forms of leucocytes in the acute infectious 
diseases, it is known that with a return to the normal of the poly- 
nuclear neutrophilic elements a temporary increase in the number 
of the eosinophiles often occurs. With the decline of the hyper- 
leucocytosis, moreover, mononuclear neutrophilic leucocytes and 
irritation-forms frequently appear in small numbers. The lympho- 
cytes remain practically uninfluenced. 

The toxic hyperleucocytoses likewise belong to this order. An 

1 Van dor Berg, Arch. f. Kindorheilk., vol. IXY. p. 321. 

2 Musser and Sailer, Phila. Med. Jour., Is98, p. 1408, and 1899, p. 89. 



00 THE BLOOD. 

increase in the number of the poly nuclear neutrophilic elements is 
thus observed in cases of poisoning with potassium chlorate, arseni- 
ous hydride, and illuminating-gas, after the administration of atro- 
pin and quinin, and also following the prolonged administration 
of chloroform and ether. 

Numerous observations show that in marked anaemia when the 
percentage of haemoglobin is low, general anaesthesia, especially if 
prolonged, is dangerous. Mikulicz holds that no general anaesthetic 
should be given under any circumstances if the haemoglobin is below 
30 per cent., and Da Costa and Kalteyer x believe that 40 per cent, 
is probably the lowest justifiable limit. As the hyperleucocytosis 
which follows the administration of ether is but slight, and disap- 
pears within twenty -four to thirty-six hours, a sudden rise in the 
number of leucocytes would indicate some post-operative complication. 

Under the heading of the toxic hyperleucocytoses Cabot also 
groups those forms which may be observed in certain cases of rick- 
ets, gout, acute yellow atrophy, advanced cirrhosis of the liver 
(especially when associated with jaundice), acute gastro-intestinal 
disorders (ptomains), acute and chronic nephritis, hydronephrosis, 
following the injection of tuberculin, the administration of thyroid 
extract, and even after the infusion of normal salt solution, and 
also after the ingestion of salicylates. 

A hyperleucocytosis affecting the polynuclear neutrophilic ele- 
ments is further observed in various forms of acute and chronic 
anaemia. This is especially marked after hemorrhages referable to 
traumatism, where the number of leucocytes may increase to 30,000 
and more. Generally speaking, the degree of hyperleucocytosis 
here is proportionate to the amount of blood lost and the re- 
cuperative power of the individual. In the human being Rieder 
noted a leucocytosis of 15,000 after a pulmonary hemorrhage in 
phthisis ; 32,600 after hemorrhage from uterine carcinoma; and 
26,500 in a case of gastric ulcer. 

In the primary forms of anaemia, if we except the myelogenous 
type of leukaemia, in which an absolute increase is associated with 
a relative decrease, hyperleucocytosis referable to the polynuclear 
neutrophilic leucocytes is not met with in uncomplicated cases. In 
the secondary anaemias, on the other hand, though usually of mod- 
erate degree, it is quite common. 

An ante-mortem hyperleucocytosis has further been described by 
Litten 2 and others in moribund individuals, in which previously no 
increase of the leucocytes had existed. 

\V~e finally recognize a cachectic hyperleucocytosis which is ob- 
served in malignant disease, phthisis, etc. 3 Ewing 4 states, however, 
that in the great majority of cases of tertiary syphilis, tuberculosis, 

1 Da Costa and Kalteyer, American Medicine, 1901, p. 306. 

2 Litten, Berlin, klin! Woch.. 1877, No. 51. 3 Eieder, loc. cit. 
4 Ewing, On the Blood, Lea Bros., 1901, p. 130. 



MICROSCOPICAL EXAMINATION OF rill-: BLOOD. 89 

nephritis, in a Large proportion of carcinomata, and in a rather 
smaller proportion of sarcomata, cachexia is unaccompanied by 
hyperleucocytosis unless there is distinct local inflammation, necro- 
sis, or hemorrhage. lie suggests that marked hyperleucocytosis in 

the course of cachexia should lead to a search for one of these com- 
plications. 

Polynuclear Eosinophilic Hyperleucocytosis (Eosinophilia). — 
Aside from the increase of the eosinophilic leucocytes which may be 
observed in children under normal conditions, eosinophilia is essen- 
tially a pathological phenomenon. 

While a relative increase of the eosinophilic leucocytes may or 
may not occur in myelogenous leukaemia, the absolnte number is 
always increased in uncomplicated cases. AVhere septic processes 
supervene, however, this increase may not occur, and the absolute 
as well as the relative number is then usually much diminished. 
For a while eosinophilia was thought to be pathognomonic of this 
form of leukaemia. But we now know that a polynuclear eosino- 
philic hyperleucocytosis occurs also in other diseases. Its constant 
occurrence in myelogenous leukaemia should nevertheless be borne 
in mind, and the diagnosis discarded whenever such au increase 
cannot be demonstrated (see also page 75). 

In bronchial asthma an increase of the eosinophilic leucocytes is 
observed quite constantly about the time of the paroxysm, and may 
amount to from 10 to 53.(3 per cent. 1 Its occurrence is of value in 
differential diagnosis, as renal and cardiac asthma are not associated 
with eosinophilia. 

An increase of the eosinophilic cells has been noted in scarlatina 
by Zappert, 2 Kotschetkoff, 3 and others, and is regarded as a favor- 
able prognostic sign. In measles, on the other hand, the number 
of the eosinophils is either normal or diminished. 

In many diseases of the skin, notably in pemphigus, prurigo, 
psoriasis, and urticaria, a marked eosinophilia may be observed, 
which in some cases (urticaria) may amount to 60 per cent, of the 
total leucocytes. Its degree is apparently proportionate to the 
amount of tissue involved. The largest actual number, viz., 4800 
per cbmm., was noted in a case of pemphigus. In leprosy percent- 
ages varying between 8.48 and (31 have been obtained. 

Especially interesting, furthermore, is the increase of the eosino- 
philic leucocytes which is observed in association with the presence 
of intestinal parasites. According to Leichtenstern, it is especi- 
ally pronounced in those cases in which Charcot-Leyden crystals 
are numerous in the feces. The greatest increase is found in 
ankylostomiasis, where 72 per cent, were counted in one case. 
In the presence of oxyurides Buckler 4 found 16 per cent. Nine- 

1 Billings, X. V. Med. Jour., vol. lxv. p. 691. 2 Loc. cit. 

3 Kotschetkoff, Central!)], f. Path.. 1892. 

4 Buckler. Munch, med. Woch., 1894, Nos. 2 and 3. 



90 THE BLOOD. 

teen per cent, were counted in association with ascarides, and Leich- 
tenstern reports one case of Taenia mediocanellata with 34 per cent. 
In a fatal infection with Balantidium coli Strong and Musgrave 
observed a relative increase, and it appears that in cases of amoebic 
colitis eosinophilia is likewise not uncommon. 

Of great practical importance is the observation, first made by 
T. E,. Brown, 1 at the Johns Hopkins Hospital, that trichinosis, 
in its acute stage at least, is associated with a very remarkable 
increase in the number of the eosinophilic leucocytes. In the 
four cases reported by him the eosinophiles reached 68.2 per cent, 
of the total leucocytes, in the first; in the second, 42.8 per cent.; 
in the third, 49 per cent.; and in the fourth, 48 per cent.; while the 
total number of leucocytes per cbmm. was 35,000, 13,000, 17,000, 
and 18,000, respectively. As the disease is much more common 
than is generally believed, and as the diagnosis, except in the most 
marked cases or in the epidemic form, is impossible without an 
examination of the blood, it is advisable to make such examina- 
tions in febrile conditions of doubtful origin, as well as in all cases 
with indefinite intestinal and muscular symptoms. Whenever an 
eosinophilia of marked grade is discovered under such conditions, 
a small bit of muscle-tissue should be excised and examined for 
trichina? directly. Brown's results have been fully confirmed by 
Thayer, Cabot, Gwyn, Blumer, Neuman, and others. 2 

As I have pointed out, the eosinophilic leucocytes are rela- 
tively diminished, and may disappear altogether in the great 
majority of the acute infectious diseases, with the exception of scar- 
latina perhaps, while hyperleucocytosis referable to the poly- 
nuclear neutrophilic cells exists. In the post-febrile period, how- 
ever, the upper limit of the normal and even a well-marked eosino- 
philia are often observed. Tiirck 3 thus found an epicritic eosinophilia 
of 5.67 (430 absolute) in a case of pneumonia, and after an attack 
of acute articular rheumatism 9.37 per cent. (970 absolute). Zap- 
pert 4 reports a case of malaria in wmich on the day following the 
last attack 20.34 per cent. (1486 absolute) were found. In the 
disease in question a moderate eosinophilia is in my experience 
the rule. 

Similar observations have been made after the injection of tuber- 
culin, where a febrile reaction has taken place. In one case reported 
by Grawitz the eosinophilia reached its highest point, viz., 41,000 
per cbmm., three weeks after the injections had been stopped. 

1 T. E. Brown, " Studies on Trichinosis, with Especial Eeference to the Eosinophilic 
Cells in the Blood," etc., Jour. Exper. Med., vol. iii. p. 315 ; Johns Hopkins Hosp. 
Bull., 1897. 

2 W. S. Thayer, Phila. Med. Jour., vol. i. p. 654. K. Cabot, Boston Med. and 
Surg. Jour., vol. cxxxvii. p. 676. Blumer and Neuman, Am. Jour. Med. Sci., vol. cxix. 
p. 14. A. D. Atkinson, Phila. Med. Jour., 1899, p. 1243. Osier and Cabot, Am. Jour. 
Med. Sci., 1899. 

3 Loc. cit. i Zappert, Zeit. f. klin. Med., vol. xxiii. p. 227. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 91 

In malignant disease 1 eosinophilia apparently occurs in only a 
relatively small percentage of cases, and when present IS usually of 

moderate grade — i. e., not exceeding 7 to 10 per cent. Occasion- 
ally, however, the increase is mosl remarkable. Reinbach thus 
cites a case of lymphosarcoma oi' the neck with metastases in the 
bone-marrow, in which 60,000 eosinophilic leucocytes were counted 
on one occasion. 

The eosinophilia which is observed in certain cases of gonorrhoea 
has been carefully studied by Owings in my laboratory. From 
an analysis of his forty-two cases it appears that with an extension 
of the inflammatory process to the posterior urethra the number of 
eases increases in which an increased percentage of eosinophils is 
found in the blood, and in cases of prostatitis eosinophilia is the 
rule. During the first week of the disease the blood is apparently 
always normal. In the second and third weeks it is normal in 
only 33 per cent, of all cases, and after two months' duration an 
increased number is still observed in 40 per cent. Occasionally the 
eosinophilia is associated with an increase of the polynuclear neutro- 
philic leucocytes. 

After extirpation, as also in chronic tumors of the spleen, eosino- 
philia has been repeatedly observed. Miiller and Riecler l report 
three cases of tumor, referable to congenital syphilis, hepatic cirrhosis, 
and neoplasm of the cranial cavity, in which 12.3, 7, and 6.5 per 
cent., respectively, were found. After extirpation of the organ an 
eosinophilia is not immediately observed, but develops only after 
many months, and is of moderate grade. 

An eosinophilia referable to drugs has also been described, 
but has attracted little attention. Two cases are reported by v. 
Noorden, who observed an increase of the eosinophils to 9 per 
cent. Both were cases of chlorosis, and in both the eosinophilia 
followed the internal administration of camphor. Similar observa- 
tions have been made in animals after poisoning with carbon dioxide. 

Mixed Hyperleucocyfcosis. — This term is applied by Ehrlich to 
that form of active hyperleucocytosis, in the production of which 
grannie-bearing mononuclear leucocytes also play a part. This con- 
dition is practically found in only one disease, viz., the myelo- 
genous form of leukaemia. Mononuclear neutrophilic leucocytes, it 
is true, are also found in other diseases which are associated with 
hyperleucocytosis, but the quotum which they furnish toward the 
iral increase is there so slight, probably never amounting to 
more than 1000 per cbmm., as scarcely to affect the total number. 

Formerly, a sharp line of distinction between simple hyperleu- 
cocytosis and myelogenous leukaemia did not exist, and leukaemia 
wis regarded as a hyperleucocytosis in which the ratio between 
the white and red corpuscles exceeded a definite proportion, which 

1 Miiller and Rieder, Deutsch. Arch. f. klin. Med., vol. xlviii. p. 105. 



92 THE BLOOD. 

was generally placed as 1 : 50. As a matter of fact, there is 
probably no other disease in which so great an increase in the 
number of the leucocytes is observed, and even at the present day 
the diagnosis of leukaemia is practically proved when such a pro- 
portion can be shown to exist. The absolute number of the leuco- 
cytes may actually exceed that of the red corpuscles. In his series 
of thirty cases Cabot found 438,000 on an average per cbmm. His 
highest ratio was 1 : 2, and the lowest 1 : 37. There are exceptional 
cases of myelogenous leukaemia, however, in which the hyperleuco- 
cytosis is not so extreme, and in which the ratio may not exceed 
1 : 200. While the enumeration of the total number of leucocytes 
is thus of unquestionable value in the diagnosis of myelogenous 
leukaemia, it alone is not the determining factor. We must know, 
on the other hand, what particular elements contribute toward the 
total increase. In the lymphatic form of leukaemia, as will be 
shown more specifically later on, the hyperleucocytosis is thus de- 
pendent upon an increase of the non-granular mononuclear elements. 
In contradistinction to this form, the hyperleucocytosis of myelo- 
genous leukaemia is essentially a hyperleucocytosis referable to leu- 
cocytes which are not seen in the blood under normal conditions, 
viz., the mononuclear neutrophilic leucocytes. As these elements 
are the bone-marrow leucocytes proper, we have in myelogenous leu- 
kaemia a true myelcemia. The number of neutrophilic mononuclear 
leucocytes met with in such cases is often most remarkable, and a 
count of from 50,000 to 100,000 in the cbmm. is by no means 
exceptional. In 18 cases reported by Cabot, the average percentage 
was 37.7, corresponding to a total number of 162,000 per cbmm. ! 

In addition to the neutrophilic myelocytes the eosinophilic mono- 
nuclear leucocytes, which normally are likewise found only in the 
bone-marrow, appear also in the blood, and constitute the majority 
of the eosinophilic cells seen in this form of leukaemia. The poly- 
nuclear eosinophilic elements are at the same time absolutely in- 
creased, but their relative percentage may be normal. This absolute 
increase is so invariable in uncomplicated cases that we must regard 
it as one of the constant symptoms of the disease. Important, 
further, is the invariable increase of the mast-cells, which is absolute. 
As a general role, their number is about one-half that of the eosino- 
philes, but occasionally they are equally numerous, and exception- 
ally even more so. Ehrlich holds that from a diagnostic point of 
view they are perhaps even more important than the eosinophilic 
leucocytes, for the reason that in contradistinction to these we 
know of no other condition in which the mast-cells are materially 
increased. 

The polynuclear neutrophilic cells and the lymphocytes, although 
absolutely increased, are relatively much diminished. Of the 
latter, only 7.6 per cent, are thus found on an average, and of the 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 93 

former, 4!*.^ per cent., as compared with 20 to 30 and GO to 70 
per cent., respectively. 

The occurrence <>i* dwarfed forms of both eosinophilic and neu- 
trophilic' polynuclear and mononuclear Leucocytes in Leuksemic Mood 
lias ahvadv been mentioned. Occasionally cells in which mitoses 
can be observed are also seen, but they are of no special interest. 

The above considerations have reference to uncomplicated cases of 
leukaemia. When septic complications occur the blood condition 
may undergo great changes. Thus, in proportion to the degree of 
infection the myelsemic picture gradually disappears, and is replaced 
by that seen in simple septic conditions. The polynuclear neu- 
trophilic leucocytes may then increase to 90 per cent., and even 
higher. 

A very rare complication is further described by Ehrlich in which 
in the terminal stage of the disease the bone-marrow apparently 
loses its power of producing neutrophilic material, and in which, as 
a result, non-granular myelocytes, so to speak, appear in the blood. 
In one case of this kind which he reports the great majority of the 
mononuclear elements, which numbered 70 per cent, of the total 
number of the leucocytes, were entirely free from neutrophilic 
granules. (See also page 75.) 

Passive Hyperleucocytosis (Lymphocytosis) . — Lymphocytosis 
is observed whenever an increased circulation of lymph occurs in 
more or less extensive lymphatic districts, the lymphocytes being 
mechanically washed into the blood-current. In a mild form it is 
thus seen in certain types of the so-called physiological hyperleucocy- 
tosis (see page 81), in which the increase in the number of the lympho- 
cytes is associated with a corresponding increase of the polynuclear 
neutrophilic elements. To a more marked degree it is seen in vari- 
ous diseases of the gastro-intestinal tract and in the infectious 
diseases of children. A w r ell-pronounced lymphsemia is tints observed 
in whooping-cough, in which an increase to four times the normal 
number may occur during the convulsive stage. The polynuclear 
cells are at the same time increased, but not to the same degree. 
De Amicis and Pacchioni l found the average number of leucocytes 
in whooping-cough to be 17,943. They state that the hyperleucocy- 
tosis is present on the first day of the disease, that it reaches its height 
in the convulsive stage, and is still demonstrable some time after 
c ssation of the typical symptoms. The small mononuclear elements 
are said to be most numerous during the first and second stages of 
the disease, and the large mononuclear cells in the third stage. 

Rickets also is almost invariably associated with a well-marked 
lymphocytosis, which is both relative and absolute. 

A relative lymphocytosis is noted in typhoid fever ; it begins about 
the end of the first week, and reaches its highest point in the stage of 

1 De Amicis and Pacchioni, Clin. med. ital , 1899, No. 1. 



94 THE BLOOD. 

defervescence. (See below.) Ewing 1 states that be has found a uniform 
relation in this disease between the lymphocytosis of the blood and 
the grade of lymphatic hyperplasia found at autopsy. He records 
an instance in which the examination of the blood led to a strong 
suspicion of lymphatic leukaemia, and in which at autopsy the mesen- 
teric glands were of unusually large size, and the edges of the partly 
necrotic intestinal ulcers rose 1.5 cm. above the mucosa. 

Following the injection of tuberculin lymphocytosis is occasionallv 
observed, and Waldstein claims to have produced a marked increase 
by hypodermic injections of pilocarpin. 

Important from a diagnostic standpoint is the fact that in malig- 
nant lymphoma lymphocytosis is constantly observed, and may be of 
very high grade. In v. Jaksck's pseudoleukemia of infants the 
increase of the leucocytes principally affects the large mononuclear 
cells. 

The highest grade of lymphocytosis, however, if we except malig- 
nant lymphoma, is met with in lymphatic leukaemia. As in mye- 
logenous leukaemia, the total number of the leucocytes is here also 
very much increased, but never to the same degree. The average 
proportion between the white and red corpuscles thus scarcely ever 
exceeds 1 : 40, corresponding to 141,000 leucocytes per cbmm. 
The highest count in Cabot's series was 220,000, and the lowest 
only 40,000. Of this number, about 90 per cent, are lymphocytes. 
Myelocytes and eosinophilic leucocytes are scanty. When septic 
processes develop in such cases, the total nmnber of the leucocytes, 
as in the myelogenous form of leukaemia, likewise undergoes a con- 
siderable diminution, but the lymphocytes still remain relatively 
increased. In one case of Cabot's, in which, as the result of septicae- 
mia, the total number of leucocytes fell to 471 per cbmm., the per- 
centage of lymphocytes still was 94.7. 

Hypoleucocytosis (Leukopenia). — In the foregoing pages it has 
repeatedly been pointed out that a qualitative diminution in the num- 
ber of the leucocytes may occur under the most diverse conditions. 
A quantitative diminution, on the other hand, viz., a diminution of 
the total number of leucocytes, is observed only in comparatively 
few diseases. 

Most important from a diagnostic standpoint is the hypoleucocy- 
tosis which in uncomplicated cases of typhoid fever is so commonly 
seen as to constitute one of the most important symptoms of the 
disease. Exceptions to this rule occur, but are not common. In 
the initial stage of the disease, owing to a concentration of the blood, 
resulting from starvation and diarrhoea, higher counts are sometimes 
observed, but as the disease progresses the number soon diminishes, 
and in the later weeks is practically always markedly below the nor- 
mal. Not uncommonly less than 2000 are counted in the cbmm., 

1 Loc, cit. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 95 

and in some instances Less than 1000 arc seen. Whenever an m- 
crease in the number of the leucocytes is observed in a case of sus- 
pected typhoid fever it is more than probable that some complicatwn 
exists or that the diagnosis is wrong, Nageli, 1 who made a careful 
study of the blood in fifty cases of typhoid fever, arrived at the fol- 
lowing results. In typhoid fever systematic blood-counting is valu- 
able both for diagnosis and prognosis. The alterations in the 
numbers (not necessarily the percentages) of the polymorphonuclear 
neutrophils, oosinophiles, and lymphocytes are characteristic in the 
different stages of the 1 disease, and are produced by the action of 
the typhoid toxins upon the bone-marrow, hindering the production 
of polymorphonuclear neutrophils and eosinophiles. The changes 
in the first stage of the disease (steadily rising temperature) are : 
a neutrophilic hyperleucocytosis of moderate degree, rapidly de- 
creasing until the neutrophiles are diminished ; a disappearance of 
the eosinophiles, and a moderate decrease of the lymphocytes. In 
the second stage (continued fever) the polymorphonuclear neutro- 
philes and lymphocytes are still further decreased, although toward 
the end of this stage the latter tend to increase again. In the third 
stage (remission) the neutrophiles become fewer, the lymphocytes 
continue to increase, and a few eosinophiles appear. In the fourth 
stage (defervescence) the neutrophiles reach their minimum, the lym- 
phocytes are greatly increased, and the eosinophiles gradually return 
to their normal number. As soon as the fever disappears the neutro- 
philes begin to increase again, and there is often for some time a 
considerable lymphocytosis. All these blood-changes are more pro- 
nounced in children. Favorable indications are the early appear- 
ance of the eosinophiles, a moderate diminution in the polymorpho- 
nuclear neutrophiles, and the extreme increase of the lymphocytes. 

Uncomplicated cases of tuberculosis are likewise not associated 
with hyperleucocytosis. But as it is very much more common to 
meet with cases in which secondary infection has taken place, lead- 
ing to hyperleucocytosis, its absence is often of value in differential 
diagnosis. According to Cabot and Warthin, a subnormal number 
of leucocytes may also be observed in acute miliary tuberculosis, 
though Kolner 2 thinks the leucocyte count important in distinguish- 
ing 1 x.'tween typhoid fever and the latter disease. 

Important, furthermore, is the hypoleucocytosis of measles, which 
is commonly observed in uncomplicated cases, and may aid in dis- 
tinguishing the disease from scarlatina. 

In severe cases of anaemia the occurrence of hypoleucocytosis is 
always a grave symptom, as it indicates an inability on the pail of 
the bone-marrow to produce a sufficient number of blood -corpuscles. 

1 Nageli, Deutsch. Arch. f. klin. Med., vol. lxvii., Parts 3 and 4. Cited by T. U. 
Brown, Maryland Med. Jour.. April, 1901. 

2 Kolner, "The Blood-changes in Typhoid Fever," Deutsch. Arch. f. klin. Med., 
vol. lx. p. 221. 



THE BLOOD. 

Ehrlich supposes that in such cases the fatty marrow of the long 

aes is not transform eel into red marrow, and he has observed 
two oases in which the correctness of this supposition was demon- 
strated at the post-mortem table. A hypolencoeyfc ~i~ of this 
order was served by Desca telle and Hofbauer 1 in live cases of 
pernicious anaemia, in torn* of chlorosis, in two of post-hemorrhagie 
anaemia, in two of liver at - ess, ne of phthisis florida, one of sepsis 
with severe anaemia, in three severe anaemias of unknown origin, in 
tw< jases :' pseudoleukemia and two of splenic anaemia. 

In uncomplicated cases of influenza the number of the leucocytes 
is commonly diminished. It may, however, be normal. When 
increased, some complication probably exists. 3 

While the by] : -is in the diseases mentioned is rarely 

extreme, most extraordinary instances of leukopenia are at times 
•untered. Ehrlich thus cites the case of a well-built young man. 
in whom brief epileptiform seizures occurred, and in one of which 
the patient died. The post-mortem exam in ation was entirely nega- 
During the three days of observation preceding death two 
examinations of the blood were made. On the first day not a single 
leue ~ old b demonstrated in ten blood films, and on the 

>nd day but one was found in the same number of specimens. 

Qf drugs, atropin. camphoric acid, tannic acid, picrotoxin. agari- 
cin. menthol, sulphonal. and several other antihydrotics cause a 
marked decrease of the leucocytes. 3 

The Drying and Staining of Blood. 

In order to obtain the best results, cover-glasses of the finest 
grade, measuring n«:>t mure than 0.08 to 0.10 mm. in thickness, are 
indispensable. They should be cleansed with special care. To 
this end. Ehrlich \s method may be fed : the glasses are 

first placed in a tray with ether for half an hour, care being taken 
that they are well separated from one another. They are then dried 
with fine linen, or so-called Joseph's paper, placed in absolute alco- 
hol for a few minutes, dried again, and kept in dust-proof glass 
dishes until needed. When once cleansed, the cover-glasses should 
be handled only with forceps, as the moisture of the hands is in 
it-elf sufficient to cause post-mortem changes in the red corpuscles. 
For this purj - -V'eeially constructed instruments, sneh as those 
suggested by Ehrlich. will be found most serviceable. One cover- 
_'. ss is grasped with the flat-bladed forceps, provide:! with a sliding 
lock Fig. 1~ and held in the left hand. The second cover is 
taken up with the uther forceps, which should have a light spring 

1 Descatelle and Hofbauer. Zeit. f. klin. Med., vol. xxxix. p. 488 

- Eieder. Munch, med. Woeh.. 1S9-2. p. 511. Head. Pediatrics. Feb. 1. 19<X). 
3 K. Bohland. "On the Effect of the Hydroties and Antihydrotics upon the Num- 
ber of Leucocvtes in the Blood."* Centralbl. f. inn. Mel 181 N . 15. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 



97 



and need not be provided with a lock (Fig. 18), and is brought in 
contact with the drop of blood, and then immediately placed 
upon the first. Providing that the glasses are of the proper 
quality and clean, the drop of blood will spread out in a uniform 
layer. Ehrlich now recommends that the top cover be slid from the 
lower cover with the fingers, by grasping the former tightly and 
drawing it away in a plane parallel to the other. But it seems to 
me that at this stage forceps should also be employed. 

Fig. 17. 




Ehrlich's cover-glass forceps. 

The drop of blood may be obtained from the tip of a finger or 
the lobe of the ear, after careful cleansing with soap and water, and, 
whenever possible, also with alcohol and ether. Under no consid- 
eration should the drop be so large that the top cover floats upon 
the blood. 

I have myself abandoned the use of cover-glasses altogether for 
the purpose of spreading the blood, and greatly prefer slides. These 
are cleansed in the same careful manner. A fair-sized drop of blood 



Fig. 18. 




Linsley's cover-glass forceps. 

is mounted near the end of one slide and spread out, with an even 
sweep, with the edge of a second slide, which is held almost ver- 
tically to the first (Fig. 19). Better spreads are thus obtained than 
with cover-glasses, and a sufficient number of leucocytes is present, 
in even one normal specimen, for the purpose of a differential count 
if a mechanical stage is available. 

After drying in the air the specimens are placed between layers of 
filter-paper, and may then be examined at leisure. If for any rea- 
son it is desired to preserve the specimens for a long time — i. e., for 
months or years — it is best to coat the blood films with a thin layer 

7 



98 THE BLOOD. 

of paraffin, which is later dissolved by immersion in toluol. In this 
manner especially valuable and rare specimens may be kept almost 
indefinitely without change ; but even without this precaution the 
blood films will remain in good condition for a long time. 

Before staining, it is often necessary to fix the albuminous 
bodies of the blood. To this end, different methods may be em- 
ployed. Immersion in absolute alcohol for from five to thirty 
minutes, or in a mixture of equal parts of absolute alcohol and 
ether for two hours, furnishes good results. There can be no 
doubt, however, that the finest pictures are obtained when the speci- 
mens have been fixed by heat. For ordinary purposes it is only 
necessary to expose the air-dried blood films to a temperature of 
from 100° to 120° C. for from one-half to two minutes, while in spe- 
cial cases a more prolonged exposure or a higher temperature may 
be required. For fixing by heat, Ehrlich recommends the use of the 

Fig. 19. 




Method of making blood smears. 



so-called Victor-Meyer apparatus in a slightly modified form. This 
is essentially a small copper kettle, covered with a thin plate, which 
is perforated for the reception of the boiling tube. If a small 
amount of toluol is boiled in this kettle for a few minutes, the cop- 
per plate is soon heated to a temperature of from 107° to 110° C, and 
retains this temperature sufficiently long for ordinary purposes. In 
the absenee of such an instrument, a small coal-oil stove, upon which 
a copper plate measuring 10 by 40 cm. is placed, will answer the 
purpose. Upon this plate the line corresponding to the desired tem- 
perature is ascertained by means of a series of drops of water, tol- 
uo I (boiling-point 110- to 112° C), xylol (boiling-point 137° to 
140° (,), etc., and noting the line at which ebullition occurs. Once 
properly replated, the apparatus, which mav be advantageously 
placed in a box, so as to guard against currents of air, will be found 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 99 

to furnish a fairly constant temperature. A drying-oven provided 
with a thermostat and thermometer may, of course, be used for the 
same purpose. Of late, formol has also been much lauded as a fix- 
ing agent, and may be used in connection with the tri-acid stain, 
hse a itoxylin and eosin, thionin, etc. A 1 per cent, alcoholic solu- 
tion is employed. This is prepared by diluting one part of formol, 
which is a solution of 40 per cent, of formaldehyde, in methyl alco- 
hol and water, with nine times its volume of water, and one 
part of the resulting solution with nine times its volume of alcohol. 
Fixation is completed in one minute, and for practical purposes it 
is necessary merely to cover the blood film with a few drops of the 
solution, which is then drained oif and replaced with the staining 
reagent directly. 

When fixed according to one of the methods described, the dried 
specimen is ready for staining. For this purpose a number of so- 
lutions may be employed, the selection of the special mixture de- 
pending upon the points to be elicited. 

Staining with Eosinate of Methylene -blue l (Jenner's Stain). 
— I now use this stain as a matter of routine iu my laboratory, and 
much prefer it to all others. It furnishes excellent results and 
yields more information than Ehrlich's tri-acid stain, which for 
many years was the standard stain in blood- work. The reagent 
is prepared as follows : equal parts of a 1.2 to 1.25 per cent, aqueous 
solution of Grabler's eosin (yellow shade), and of a 1 per cent, aqueous 
solution of methvlene-blue are mixed in an open basin, thoroughly 
stirred and set aside for twenty-four hours. The resulting precipi- 
tate is filtered off, dried, powdered, washed with water, again filtered, 
and dried. Of the dye which has thus been prepared, a 0.5 per 
cent, solution in pure methyl alcohol is made, to which I further 
add about 10 per cent, of glycerin. With this solution the cover- 
glass specimens or, as I prefer, the slides, are stained for about 
five minutes without previous fixation ; the excess of stain is 
rapidly poured off, and the specimen rinsed until the film presents 
a pink color. It is then dried in the air, rapidly passed though the 
flame of a Bunsen burner, and mounted in balsam or oil of cedar ; 
or, if slides are used, the specimens may be examined in oil of cedar 
directly. 

The red corpuscles are stained a terra-cotta color, the nuclei of the 
leucocytes are blue, the plaques mauve, the neutrophilic granules a 
purplish red, the eosinophilic granules a bright red, and the basophilic 
granules a dark violet. Malarial organisms and bacteria can be 
demonstrated at the same time ; they are colored blue. The basophilic 
granules which are encountered in granular degeneration of the red 
corpuscles are likewise blue, while red corpuscles which are under- 
going polychromatophilic degeneration present a tint in which the 

X C. E. Simon, "Eosinate of Metkyleuc-bliie." Maryland Med. Jour., April, 1900. 

L.ofC 



100 THE BLOOD. 

terra-cotta color becomes less and less distinct, and the blue color 
more and more predominant (Plate III.). 

Staining with Ehrlich's Tri-acid Stain. — This method is like- 
wise one of the most useful and convenient for all practical pur- 
poses. The information which it offers is not so complete, however, 
as that furnished by the eosinate of methylene-blue. Great care, 
moreover, is necessary in the preparation of the stain, and chemically 
pure dyes are absolutely essential. Ehrlich recommends the crystal- 
line dyes prepared by the Actiengesellschaft ftir Anilinfarbstoffe in 
Berlin. In my experience I have found the well-known prepa- 
rations of Dr. G. Griibler & Co. of Leipzig entirely satisfactory. 
Saturated aqueous solutions of orange-G, acid fuchsin, and methyl- 
green are first prepared, and allowed to clear by standing for at least 
one week. The various ingredients are then mixed in the order 
given below, in one and the same measuring glass. After the 
addition of the methyl-green solution the mixture should be 
thoroughly stirred until the final ingredients have been added. 
When completed, trial specimens are stained in order to ascertain 
whether the requisite amounts of acid fuchsin and methyl-green have 
been added. Should the neutrophilic granules be insufficiently 
stained, a few drops more of the acid fuchsin or methyl-green, or of 
both, are added, as the ease may be. 

Orange-G solution 13-14 c.c. 

Acid fuchsin solution 6-7 c.c. 

Distilled water 15 c.c. 

Alcohol 15 c.c. 

Methyl-green solution 12.5 c.c. 

Alcohol 10 c.c. 

Glycerin 10 c.c. 

The solution is ready for use at once and improves with age. 1 
If properly prepared, the nuclei of the leucocytes will be stained 
greenish, the eosinophilic granules a copper color, and the neutro- 
philic granules violet. The nuclei of the basophilic leucocytes are 
stained a pale green, while the surrounding protoplasm remains 
colorless. Ordinarily the red corpuscles are stained orange, but in 
cases of chronic anaemia, more especially, individual corpuscles may 
be seen which do not take on a pure orange tint, but a mixed tint, 
in which the fuchsin predominates to a greater or less degree. This 
altered susceptibility on the part of the red corpuscles to different 
dyes lias been designated as anaemic or polyehrmnatophilic degenera- 
tion (see page 63). 

Staining with Aronsohn and Philip's Modified Tri-acid Stain. 
— Saturated solutions of orange-G, acid rubin, and methyl-green are 
prepared, and the various ingredients mixed in the following pro- 
portion- ; 

liable (ri-acid stain is sold by Messrs. Hynson & Westcott, of Baltimore, Md., 
from whom tin- ( oainate of metkylene-blue may likewise be procured. 






MICROSCOPICAL EXAMINATION OF THE BLOOD. 101 

Orange-G solution 55 c.c. 

Acid rubin solution 50 c.c. 

Distilled water 100 c.c. 

Alcohol 50 c.c. 

To this mixture are added : 

Methyl-green solution 65 c.c. 

Distilled water 50 c.c. 

Alcohol 12 c.c. 

The mixture should stand for from one to two weeks before being 
used. A drop of the reagent added to a Petri dishful of water is 
used for staining purposes. The specimens must be carefully fixed 
by heat. Exposure to the stain for twenty-four hours is required. 
They are then rinsed in water and absolute alcohol, cleared in ori- 
ganum oil, and mounted. The various elements are stained as with 
Ehrlich's stain. 

Neusser's Stain. — In order to stain the basophilic perinuclear 
granules of Neusser, the following modification of Ehrlich's tri-acid 
stain should be employed : 

Saturated aqueous solution of acid fuchsin 50 c.c. 

Saturated aqueous solution of orange-G 70 c.c. 

Saturated aqueous solution of methyl-green 80 c.c. 

Distilled water 150 c.c. 

Absolute alcohol 80 c.c. 

Glycerin 20 c.c. 

The specimens require only a slight degree of fixation, and are 
stained as with Ehrlich's tri-acid stain. 

Staining with Ehrlich's Haematoxylin-eosin, or Orange-G 
Solution. — The solution is prepared by dissolving 2 grammes of 
hematoxylin in a mixture of 100 grammes each of distilled water, 
alcohol, and glycerin. To this solution 10 grammes of glacial 
acetic acid and an excess of alum are added. After exposure to the 
sunlight for from four to six weeks about 0.5 gramme of eosin or 
orange-G is added. 

The specimens are fixed in absolute alcohol, or by heat (a brief 
exposure only is necessary). They are then left in the stain, in the 
sunlight, for from one-half to two hours, when they are thoroughly 
washed in water, dried, and mounted. 

The red corpuscles and eosinophilic granules are colored a bright 
red, the nuclei of normoblasts and megaloblasts a deep black, the 
bodies of the leucocytes a light lilac, and their nuclei a dark lilac. 
The bodies of the lymphocytes, however, are scarcely stained at all, 
while their nuclei appear only a shade lighter than those of the 
nucleated red corpuscles. 

Staining with Oheczinsky's Eosin-methylene-blue Solution. — 



102 THE BLOOD. 

This consist- : - e.e. of a concentrated aqueous solution of 
inethylene-blue. 20 : ■'..'. per cent, solution of eosin in 70 

per cent, alcohol, and -40 c.c. of distilled water. The solution 
keeps fairly well, but should always be filtered before using. A 
slight degree : fixation only is ne cessary. The specimens are 
stained for from six to twenty-four hours in air-tight watch-crystals 
at a temperature of from 37 D to 40 : C . 

The red corpuscles and eosinophilic granules re -:ained a bright 
red. the nuclei and basophilic granules a deep blue, and the malarial 
rganisms a light sky-blue. The stain is very useful in studying 
nuclei, and the eosinophilic and basophilic granule 

Staining with Ehrlich's Tri-glycerin Mixture. — Thi~ is o:-- 

: _ grammes each of eosiD. aurantia, and nigrosin in 30 

grammes : glycerin. These ostituents are brought into solution 

by keeping the mixture in the warm chamber " to 40° C.) for 

about one week. 

The specimens must be well fixed, an exposure to a temperature 
of about 110° C. for at least two hours being best. They are then 
allowed to remain upon the stain for from sixteen to twenty-four 
hours, when they are rinsed in water, dried, and mounted as usual. 
The red corpuscles are colored orange, the bodies of the leucocytes 
a dirty gray, with dark nuclei, and the eosinophilic granules a 
bright red. 

Staining with Ehrlich's Neutral Mixture. — This : nsists of 
five volumes of a saturated aqueous solution of acid fuchsin, to 
which one volume of a saturated aqueous solution of methylene-blue 
is slowly added, while shaking. The mixture is treated with five 
volumes of distilled water and filtered, after having stood for several 
days. The specimens are stained for from five to twenty minutes. 
Only a slight degree of fixation is — ry. 

The red corposcli - stained the color of fuchsin, their nuclei, 

as well as se of the leucocvtes, are black, or a light lilac, the 
grannies red, and the neutrophilic granules violet* 
Staining with Eosin. — It is most convenient to use a 0.2S t 
per cent, ale - ution, with which the specimen is stained 

for about one minute. If a 0.1 to 0.5 per cent, aqueous solution 
aployed, an exposure for from ten to twenty minutes is necessary. 
fixation need only be slight. 

re stained a bright red, the protoplasm of 

:aint red, while the eosinophilic granules are deeply 

vd. 

Basic Double Staining. — A ~a turated aqueoiis solution of methyl- 

small amount of an alcoholic solution of 

* u * brief fixation the specimens are stained for five 

minutes. The nuclei appear green, the red corpuscles red, and the 

>f the lymph lor of fuchsin. The stain is 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 103 

especially serviceable for demonstration purposes, in eases of lym- 
phatic Leukaemia. 

Staining with Eosin-methylal and Methylene -blue. — The re- 
agent consists of 10 e.c. of a 1 per cent, aqueous solution of eosin, 
to which 8 e.c. of methylal and 10 e.c. of a saturated aqueous solu- 
tion of chemically pure niethylene-blue have been added. The 
mixture is ready for use at once, and furnishes very good results. 
Unfortunately, however, it is very unstable and had better be pre- 
pared in small quantities as needed. The best results are obtained 
it' the specimens have been previously carefully heated for about two 
hours. Staining for one or two minutes is sufficient. The baso- 
philic granules are colored a pure blue, the eosinophilic granules red, 
and the neutrophilic granules a reddish blue. 

Special Staining of Basophilic Leucocytes. — The staining fluid 
consists of 100 e.c. of distilled water, to which 50 e.c. of a saturated 
alcoholic (absolute) solution of dahlia are added. This solution, upon 
clearing, is mixed with 10 to 12.5 e.c. of glacial acetic acid. The 
specimens are stained for from five to ten minutes. 

A saturated aqueous solution of methylene-blue may be used for 
the same purpose and in the same manner. 

With the exception of bacteria, only the basophilic leucocytes are 
stained, while the neutrophilic leucocytes are but faintly tinged. 

As I have indicated, good results are also obtained with the eosin- 
ate of methylene-blue, and I no longer make use of a special stain 
in order to demonstrate the basophilic granules. 

Michaelis' Eosin-methylene-blue Stain. 1 — Two solutions are 
prepared, viz., one containing 20 e.c. of absolute alcohol and 20 e.c. 
of a 1 per cent, aqueous solution of chemically pure methylene- 
blue, the other consisting of 28 e.c. of acetone and 12 e.c. of a 1 
per cent, aqueous solution of chemically pure eosin. The two solu- 
tions are kept in separate bottles, and are mixed in equal proportions 
immediately before using. The mixture is placed in a watch-crystal 
and covered without delay. The blood films are fixed by heat or by 
immersion in absolute alcohol for from one to twenty-four hours, 
and are then placed in the stain, face downward, for from one-half to 
ten minutes, the time varying with each preparation. The staining 
should be stopped as soon as the blue color, which is first observed, 
has turned t<> red, as otherwise the nuclei of the leucocytes will be 
decolorized. Should the leucocytes, moreover, be numerous, it is best 
to stop even before this point has been reached. If, on the other 
hand, the blue stain has acted too energetically, the specimen is 
stained a little longer. The preparation- are finally rinsed in water, 
thoroughly dried, and mounted as usual. The various elements of 
the blood are stained as with the eosinate of methylene-blue. 

1 L. Michaelis, " Eine Universal f iirbemethode f. Blutpraparate," Deutscli. med. Woch., 
1899, p. 490. 



104 :hi 11. :z 

Distribution of the Alkali in the Blood. 

A g idea of the distribut: m : the alkali in the blood 

may be formed by making use of the following method, suggested 
by Ehrlieh : a drop of blood is carefully spread between two eover- 
_ sseSj when the air-dried specimens are immediately placed in a 
watch-crystal, containing a solution of the free staining acid of ery- 
throsin in chloroform. In a few minutes the specimens have 
ass amed a bright-red color, when they are transferred lor a minute or 
two into a crystal containing chloroform. While still moist they 
are then imbedded in Canada balsam. Prepared in this manner, 
the alkaline elements of the blood are colored red. The plasma 
presents a distinctly red color, while the red corpuscles have not 
taken up the stain. The protoplasm of the leucocytes and especially 
of the lymph icyteSj as alsc the plaques, the nbrin-nlaments, and the 
bits of protoplasm derived from the leucocytes are all stained a deep 
red, while the nuclei of the leucocytes remain colorless. If mala- 
rial organisms are present, these are likewise stained. 

In order to prepare the stain, the following procedure mav be em- 
ployed : a saturated aqueous solution of erythrosin (tetra-iodo-fluor- 
eseixi ) is acidified with dilute hydrochloric acid, and the staining 
acid, which is thus precipitated, collected on a filter, after having 
been washed with distilled water. The precipitate is dissolved in 
chloroform, to which it imparts an orange color. This solution is 
employed for stain ing . In ex — care should be had that the 

glass utensils which are used are freed from adherent alkali, by wash- 

g with concentrated acids and then with distilled water. 

The Plaques. 

In addition to tr ind the red corpuscles large num- 

- : small, roundish elements, measuring about 3 p. in diameter, 
are encountered in the blood, which are free from coloring-matter 
and may be frequenT ed collected into small heap% resem- 

bling ■ bunch— f grapes in lightly with both acid and basic 

dyes l-plates >r plaques of Bizzozero. Accord- 

- sent ordinary red corpuscles in an early 

hence been termed haematMmte. 
This opinic s not shared by many baanatologists, and 

^ «s i hat they are derived from the red coq>uscles and 

_ ilation of the blood. According to 
H ^y represent fragments of the nuclei of disin- 

I _ 

ries under normal conditions 
percbinm. Brodie and Russell, how- 
small, and state that if their im- 
od of counting is used, an average of 635,300 will be 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 105 

found in the ebnim. The ratio between the plaques and the red 
corpuscles would thus be 1 : 7.8, accepting 5,000,000 red corpuscles 
as the average normal number for the red. A large increase is ob- 
served in post-hemorrhagic anaemia and in chlorosis, coincidently 
with an increased coagulability of the blood ; while in purpura, in 
which this is always much diminished, a corresponding diminution 
of the plaques has been noted. In malaria and various febrile dis- 
eases smaller numbers than usual are also said to occur. Hayem's 
statement that they occur in greatly diminished numbers in the 
blood of pernicious anaemia lacks confirmation. 

Owing to the rapidity with which the plaques tend to agglutinate 
after the blood has been drawn, it is usually not possible to study 
the individual bodies in fresh specimens, mounted in the ordinary 
way. Various methods have hence been devised to overcome this 
difficulty. One of the best is to place a drop of Hayem^s fluid 
(see page 107) upon the finger, and to puncture this through the drop. 
For ordinary purposes this method will suffice, but if it is desired 
to count the plaques, the procedure of Brodie and Russell should be 
employed (see page 110). 

Literature. — Bizzozero, " Ueber einen neuen Formbestandtheil d. Blutes," etc., 
Virehow's Archiv, vol. xc. Howell, " The Life-history of the Formed Elements of 
the Blood," etc., Jour. Morphol., 1891, vol. iv., p. 57. Brodie and Russell, "The Enu- 
meration of the Blood-platelets," Jour. Physiol., 1897, Nos. 4 and 5. 

The Dust Particles or Hsemokonia of Miiller. 

These may be seen in any fresh specimen of blood mounted in 
the usual manner. They are small, generally round, sometimes 
dumb-bell-shaped, colorless, highly refractive granules, which mani- 
fest very active molecular movements. They occur in the plasma 
of the blood, and are apparently not connected w T ith the process of 
coagulation. Muller found them abnormally numerous in a case of 
Addison's disease, while they were diminished during starvation and 
in various cachectic conditions. Stokes and Wegefarth regard these 
granules as identical with the neutrophilic and eosinophilic granules 
of the leucocytes. They suppose, moreover, that the bactericidal 
power of the leucocytes of the blood, and of the serum of man and 
many animals, is due to their presence. 

Literature. — H. F. Muller, " Ueber einen bisher nicht beacbteten Formbestand- 
theil d. Blutes," Centralbl. f. allg. Path. u. path. Anat., 189G, p. 9:29. W. R. Stokes 
and A. Wegefarth, " The Presence in the Blood of Free Granules, etc.. and their Pos- 
sible Relation to Immunity," Bull. Johns Hopkins Hosp., 1897, p. 246. E. B. San- 
gree, ' : Leucocytic Granules," etc., Phila. Med. Jour., 1898, p. 472. 

The Enumeration of the Corpuscles of the Blood by the Method 

of Thoma-Zeiss. 

Of the various instruments employed for the enumeration of the 
blood-corpuscles, that of Thoma-Zeiss is the most satisfactory (Fig. 20). 



106 



TEE BLOOD. 



It consists of a capillary pipette (£), having a bulb in its upper 
third, the lower end being graduated in parts numbered from 0.1 
to 1, while above the bulb a mark bearing the number 101 is placed. 
With this goes a counting-chamber (B) measuring exactly 0.1 mm. 



Fig. 20. 










Wd 1 

0.100 mm. I #7% I 
4<yo mm. I %3f I 





Thoma-Zeiss blood-counting apparatus. 



in depth, the floor of which is ruled into sets of 16 small squares, 
each small square underlying a space of 40 1 00 cbmm. 

Enumeration of the Red Corpuscles. — In order to count the 
red corpuscles with this instrument, the tip of a finger or the lobe 
of the ear is punctured with a sharp-pointed scalpel, after having 
been carefully cleansed with soap and water, alcohol, and finally 
with ether. The exuding blood is drawn into the capillary tube to 
a given mark, generally to 1 or 0.5, according to the degree of dilu- 
tion desired, care being taken that no pressure is made upon the 
finger, and that the tip of the instrument comes in contact with the 
blood only. The point of the tube is then rapidly wiped, and the 
blood diluted with a 3 per cent, solution of common salt, which is 
drawn into the pipette to the mark 101. 

Toison's fluid is still more convenient as a diluent, as the leuco- 
cytes are stained by the methyl-violet, and are thus rendered more 
easily visible. Its composition is the following : 

Distilled water 160 grammes. 

Glycerin 30 " 

Sodium sulphate 8 " 

Sodium chloride 1 gramme. 

Methyl-violet 0.025 " 

Other solutions such as a 15-20 per cent, solution of magnesium 
sulphite, a :, per cent, solution of sodium sulphate, Hayem's or Pa- 
cini'- fluid, may also be employed for the same purpose. 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 



107 



Formula of I Tavern's fluid: 

Mercuric chloride 0.5 gramme 

Sodium sulphate 5.0 grammes 

Sodium chloride 2.0 " 

Distilled water 200.0 

Formula of Pacini's fluid •. 

Mercuric chloride 2.0 grammes 

Sodium chloride 4.0 " 

Glvcerin 26.0 " 

Distilled water 226.0 " 

The contents of the bulb are now thoroughly mixed by shaking, 
in which the glass bead (2£) contained in the bulb aids very ma- 
terially. The contents of the capillary tube are then cautiously 
expelled, as this contains only the diluting fluid. A drop of the 
mixture is now placed on the counting-chamber, and the cover-slip 
(/•) adjusted, bubbles of air being carefully excluded. When properly 
prepared, Newton's colored rings should be seen at the margin of the 
drop. After allowing the corpuscles to settle — from three to five 
minutes are generally sufficient — they are counted. At least one 
whole field, or, if special accuracy is required, two whole fields, should 
be gone over — L e., 200 or 400 small squares, respectively, when 
counting the red, and at least four whole fields when counting the 
white. 

It is convenient to count the red corpuscles in sets of four small 
squares, lying side by side in a horizontal direction, note being 



Fig. 21. 



*0 o * .* ° c *« ° ° o C „° ° °c '• t %" 



Appearance of blood in the Thoma-Zeiss cell 

taken of every corpuscle that touches the upper and left boundary- 
lines of the large squares, no matter whether the body of the cell 
lies inside or outside of these lines ; those touching the lower and 
right lines are ignored. It will be noted that every large square is 
separated from its neighbor, both horizontally and vertically, by a 
row of small squares traversed by a mesially placed line, which 



108 THE BLOOD. 

serves as a guide to the next large square (Fig. 21). As a general 
rule, it will be found most convenient to ignore these intermediary 
squares, account being taken only of the large ones. 

In order to calculate the number of red corpuscles contained in 
one cbmm. of blood the total number noted is divided by the num- 
ber of small squares counted, the result giving the average number 
contained in one small square — i. e., in 40 1 QQ cbmm. One cbmm. 
of the diluted blood will then contain 4000 times this number, and 
one cbmm. of undiluted blood the product of this figure and the 
degree of dilution. 

Example. — Supposing that 1200 red corpuscles were counted in 
400 small squares, the average number contained in one — i. e., in 
ToVo cbmm. of diluted blood — would be 3, corresponding to 12,000 
corpuscles for each cbmm.; supposing, further, that the blood was 
diluted 200 times, there would be 2,400,000 in 1 cbmm. of the un- 
diluted blood. 

Enumeration of the White Corpuscles. — The leucocytes when 
present in increased numbers may also be counted with this instru- 
ment, but not less than four whole fields should be covered in the 
examination. 

With an approximately normal number of leucocytes, however, it 
is necessary to resort to special pipettes, which are constructed for 
a dilution of 1 : 10 or 1 : 20. But with the diluting fluids men- 
tioned above, it would be impossible to count the leucocytes in a 
mixture of this proportion, as a large number would be concealed by 
the red corpuscles. A 0.3-0.5 per cent, solution of acetic acid is 
therefore used, which dissolves the red corpuscles and renders the 
nuclei of the white more distinct. In the absence of a special pipette, 
an ordinary 1 cbmm. pipette accurately graduated in tenths may be 
employed. 0.9 c.c. of the acetic acid solution is placed in a watch- 
crystal and there mixed with 0.1 c.c. of blood, when the counting- 
chamber is filled and covered as described. In order to obtain 
greater accuracy, the entire field of the microscope is now counted, a 
lower power being employed with which the rulings are just visible. 
The cubic contents of the field of vision are now determined accord- 
ing to the formula Q = nr 2 X 0.1. Q represents the cubic contents 
to be determined ; r, the radius, which is readily ascertained by 
noting the number of vertical lines which cross the field, bearing in 
mind that the distance between two of these is equivalent to -^ mm. 
(the area of each small square being ^ mm.), and dividing the 
transverse distance by 2 ; the value n is constant, 3.1416 ; 0.1 rep- 
resents the depth of the chamber. 

If n represents the number of white corpuscles contained in the 
field, the cubic contents of which are Q, the number of corpuscles, 
N, contained in 1 cbmm. of the diluted blood is ascertained accord- 
ing to the equation 



MICROSCOPICAL EXAMINATION OF THE BLOOD. 109 



Qin;: 1 : N } and N= --• 

As the blood has been diluted ten times, the value of iVfor the 
non-diluted blood will be -J, where n represents the total number of 
leucocytes and / the number of fields counted. 

Example. — Supposing the number of leucocytes found in 50 fields 
to have been 600, and the cubic contents of each field 0.03925 
cbmm., the total number of leucocytes contained in 1 cbmm. of un- 
diluted blood would be 3057, as ascertained by the equation 

N _ 10.?i _ 10X600 



f.Q 50X0.03925 

Special care should be taken to keep the pipette in a clean condi- 
tion. After use, it should be rinsed with : (1) the diluting fluid, (2) 
distilled water, (3) absolute alcohol, and (4) ether. If dust or coag- 
ulated blood adheres to the pipette, it should be removed by repeated 
rinsings with strong acids or alkalies, assisted if necessary by a 
bristle. 

Indirect Enumeration of the Leucocytes. 

The number of leucocytes may also be ascertained in an indirect 
manner by accurately counting the number of red corpuscles and leu- 
cocytes in dried and stained specimens with a Zeiss net-micrometer, 
the ratio between the two varieties being thus ascertained. With 
the Thoma-Zeiss apparatus the number of red corpuscles contained 
in 1 cbmm. of blood is then determined, when the corresponding 
number of leucocytes is found according to the equation 

//? 

/ : r : : L : R, and L = — > 
' r 

where I and r represent the number of leucocytes and red corpuscles, 
respectively, as counted in the dried specimens, and where L indi- 
cates the unknown number of leucocytes and R the number of red 
corpuscles in 1 cbmm. of blood, as determined with the Thoma- 
Zeiss instrument. 

Example. — Supposing that 700 red corpuscles and only 1 leuco- 
cyte were counted in the dried specimen, and that an estimation of 
the red corpuscles with the Zeiss apparatus indicated the presence 
of 5,000,000 in 1 cbmm. of blood, the corresponding number of 
leucocytes would be 7142, as is apparent from the calculation : 

T = IR __ 1 X 5000000 _ 71 4 2 
r 700 

Notwithstanding the apparent simplicity of the process of blood- 
counting, a great deal of experience is required in order to obtain 



110 THE BLOOD. 

results which are free from unavoidable errors. In using the Thoma- 
Zeiss apparatus errors of more than 2 to 3 per cent, should not 
occur. 

Differential Enumeration of the Leucocytes. — A differential 
enumeration of the various forms of leucocytes can be carried out 
only in specimens which have been stained so as to bring out the 
different granulations. Ehrlich's tri-acid stain has heretofore been 
employed almost exclusively for this purpose. It gives good results 
if it has been prepared carefully, but it does not color the basophilic 
granules. During the past two years I have used the eosinate of 
methylene-blue almost exclusively, and have come to the conclusion 
that in many respects it is better than Ehrliclr's stain. The neutro- 
philic granules are well shown and the stain can be prepared without 
difficulty. 

In making a differential count of the leucocytes I go over the 
preparation as thoroughly as possible, beginning at the left upper 
corner. A movable stage is, of course, very convenient, but is not 
a necessity. The individual leucocytes are classified as they are met 
with, and the percentages finally calculated. To obtain accurate 
results, at least 1000 should be counted. 

Enumeration of the Plaques. 

Method of Brodie and Russell. — The method is an indirect one. 
First the red corpuscles are counted in the usual manner. A drop 
of the staining fluid, composed of equal parts of a 2 per cent, solu- 
tion of common salt and a saturated solution of dahlia in glycerin, 
is then placed upon the finger, when this is punctured through 
the drop and the blood allowed to mix with the reagent. In this 
mixture the ratio between the plaques and the red corpuscles is 
ascertained, and the total number of plaques contained in 1 cbmm. 
of blood determined by calculation. The plaques are stained the 
color of dahlia and can readily be counted. Rapid work, however, 
is essential, as the staining fluid soon attacks the red corpuscles. 

Ehrlich suggests the enumeration of the plaques in air-dried 
specimens which have been stained with acid erythrosin. Owing 
to the relatively large amount of alkali which the plaques contain, 
they are stained an intense red with this reagent (see page 104). 

Rosin proposes that the air-dried specimens be fixed for twenty 
minutes by exposure to the vapors of osmic acid, and then stained 
in a concentrated aqueous solution of methylene-blue. 

The Haematokrit. 

Within late years the centrifugal machine has also been applied 
to blood-counting, but has not become very popular in the clinical 
laboratory. 



MICROSCOPICAL EXAM [NATION OF THE BLOOD. 



Ill 



Daland's latest modification of the instrument, originally devised 
by Hedin, is represented in the accompanying illustrations. It 
consists essentially of a metallic frame (Fig. 23), supported upon a 



Fig. 




Fig. 23. 



QiBi 




Daland's haematokrit. 



spindle which can be rotated at high speed, one single revolution 
of the large handle causing 134 revolutions of the frame. Two 
glass tubes 50 mm. in length and having a diameter of 0.5 mm. 
accompany the instrument. Each tube (Fig. 25) bears a scale 



112 



THE BLOOD. 



ranging from to 100, the individual divisions of which are ren- 
dered easily visible by a lens-front. The outer ends of the tube fit 
into small, cup-like depressions, the bottoms of which are covered 
with thin rubber. The inner extremities are held in position by 



Fig. 24. 




Fig. 25. 




Daland's hseinatokrit. 



springs. The instrument should be secured firmly to a solid table 
and oiled daily when in use. 

To examine the blood, a rubber tube, provided with a mouth- 
piece (Fig. 26), is slipped over the end of one of the glass tubes, 
and the tube filled completely by suction from a drop of blood 
obtained from the finger or the ear. The blunt point of the tube 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 113 

is covered quickly with the finger and the tube fixed in the frame. 
This is rotated at a speed of 10,000 revolutions for two or three 
minutes, when the volume of the red corpuscles is directly read off. 
In healthy individuals the volume of the red corpuscles is about 50 
per cent., so that in a given ease a proportionate expression of the 
percentage of corpuscles, as compared with the normal, can be ob- 
tained by multiplying the figure upon the scale by 2. 

As it* has been ascertained that 1 per cent, by volume represents 
about 100,000 red corpuscles, it is only necessary to add five ciphers 
to the percentage-volume found in order to obtain the number of 
red corpuscles in 1 cbmm. of blood. 

Fig. 26. 




Suction-tube of Daland's hsematokrit. 

Example. — Supposing that in a given case the reading was 35 ; by 
multiplying this figure by 100,000, 3,500,000 would represent the 
number of red corpuscles contained in 1 cbmm. of blood. 

If normal blood is examined with the hsematokirt, the leucocytes will 
be seen to form a narrow w r hite band at the central end of the column 
of red corpuscles ; a hyperleucocytosis is thus readily recognized. 

I am personally not an enthusiast, as regards the use of the 
hsematokrit in blood- work. The instrument in my laboratory is a 
hand centrifuge, and I freely confess that I am in fear of an accident 
whenever the attempt is made to rotate the attachment at the pre- 
scribed rate of speed. This, moreover, is a feat in itself. Others, 
who are using electric centrifuges, speak more favorably. 

BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 

It is generally admitted that micro-organisms do not normally 
occur in the blood ; in conditions which may be said to stand mid- 
way between health and disease, however, they are met with at times. 
In patients suffering from furuncles, for example, bacteria may be 
found in the skin, in the lymph-glands, and even in the blood of 
neighboring tissues, other symptoms of disease being absent. To 
this condition the term "latent microbism" has been applied by 
Verneuil. Under truly pathological conditions, on the other hand, 
micro-organisms are not infrequently found, and an examination with 
this view will often lead to a correct diagnosis. 

For ease of reference, the various organisms that may be met Avith 



Ill THE BLOOD. 

in the blood in disease will be described under the headings of the 
respective diseases in which they are found. 

Typhoid Fever. 

Recent researches have shown that in typhoid fever the specific 
organism (Plate XII., Fig. 3) can be isolated from the blood di- 
rectly in a fairly large percentage of cases and at a time when the 
AYidal reaction (see below) may not as yet be obtainable. Schott- 
miiller thus found the organism in forty cases out of fifty, Castellani 
in twelve out of fourteen, and Auerbach and Unger in seven out 
of ten. Xeuhaus, Xeufeld, Curschniann, Eumpf, and others had 
previously shown that the bacillus may at times be cultivated from 
the blood taken from the roseolar spots. 

The blood is withdrawn by means of a sterilized syringe from 
one of the superficial veins of the arm ; 300 c.c. of bouillon are 
inoculated with 30 drops, of the fresh blood and examined after 
from eighteen to twenty -four hours. If a negative result is obtained 
in the hanging drop, a further examination is made twenty -four 
hours later. At first the bacilli are but little active, but on further 
cultivation and reinoculation their motility increases. For purposes 
of identification they are grown on agar slant, in milk, bouillon, glu- 
cose, and further tested with an actively agglutinating serum (see 
below). Positive results have in this manner been obtained thirty- 
six hours after the first inoculation. 

Literature.— Xeuhaus, Beriin. klin. Woch.. 1886, Nos. 6 and 24. Schottrnuller, 
Deutsch. med. Woch., 1900, No. 32. Castellani, cited in Presse med., June, 1900. 
Auerbach u. Unger, Deutsch. med. Woch.. 1900, No. 29. Cole, Johns Hopkins Hosp. 
Bull., 1901, p. 203. 

Widal Serum Test. — Of greater practical utility than the culti- 
vation of the typhoid bacillus from the blood is the fact that the 
blood-serum of patients affected with typhoid fever possesses the 
property of causing arrest of motility and agglutination of the spe- 
cific bacilli. This observation, originally made by PfeifPer, was first 
utilized for diagnostic purposes by Widal, in 1896. The method 
which bears his name has now been quite generally adopted in the 
clinical laboratory, and must be regarded as a most valuable aid in 
the diagnosis of typhoid fever. The reaction occurs in over 95 per 
cent, of undoubted cases, and may appear as early as the first day 
of the disease, meaning thereby the first day that the patient spends 
in bed or the fifth day of general malaise. Such instances, however, 
arc very uncommon, and, as a general rule, a positive result is ob- 
tained only after the fifth or sixth day in bed. In a small number of 
positive eases, on the other hand, the patient may pass through the 
entire course of the disease, and present typical clumping only dur- 
ing convalescence or a subsequent relapse. In every case, therefore, 
in which no reaction is obtained upon first trial, the test should be 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 115 

repeated at regular intervals throughout the disease until a definite 
result is obtained. Intermittence of the reaction, moreover, is very 
common, and emphasizes still further the necessity of frequent exami- 
nations in apparently negative cases. 

AVhile in some instances the reaction disappears very soon after 
the temperature reaches normal, and even earlier, it generally con- 
tinues into convalescence, and may be observed for months and years 
after the attack. Cases have thus been recorded in which a positive 
reaction could be obtained as long as thirty-seven years after in- 
fection. 

The question, whether or not Widal's reaction is a specific reac- 
tion of the typhoid organism, can, I think, be answered in the 
affirmative, notwithstanding the facts that at times cases of true 
typhoid fever are seen in which no clumping is obtained, and that the 
reaction has been observed in cases which were apparently non- 
typhoid. Such exceptions, no doubt, are due in part to faulty tech- 
nique, viz., to too low a degree of dilution of the serum, the use of 
old or impure cultures, too long a time-limit of observation, single 
negative tests, etc. On the other hand, there can be no doubt that 
typhoid bacilli are at times present in the body without giving rise 
to symptoms of typhoid fever. In a case of cholelithiasis, reported 
by Cushing, typhoid bacilli were thus found in the gall-bladder, and 
distinct clumping was observed with a dilution of 1 : 30, although 
no history of typhoid fever could be obtained. There can further 
be no doubt that individuals exist who are naturally immune against 
typhoid fever, and that some of the positive results which have been 
obtained in perfectly healthy individuals who have never had typhoid 
fever may be explained in this manner. 

While the reaction may hence be regarded as a specific infectious 
reaction of the typhoid organism, nevertheless its value in diagnosis 
is limited. This is owing largely to the fact that in many cases a 
positive result is not obtained before the end of the second or third 
week, and may even be delayed until a relapse occurs. Its per- 
sistence for years after infection is also an obstacle to its general 
utility, not to speak of its occurrence in apparently healthy individ- 
uals and in diseases in which an association with the typhoid organ- 
ism is not apparent. 

WidaVs test is a most valuable aid in the diagnosis of typhoid fever , 
but cannot be relied ujjon to the exclusion of other symptoms. 

Technique. — The method is based upon the fact that typhoid 
serum will cause arrest of motility and agglutination of the specific 
bacilli even when diluted, whereas clumping of the same organism is 
obtained only with sera from other diseases and healthy individuals 
when these are used in a more concentrated form. The time-limit 
at which clumping occurs is likewise an important factor, as non- 
typhoid sera are at times met with in which, notwithstanding a cer- 



116 THE BLOOD. 

tain degree of dilution, agglutination occurs, providing that the speci- 
men is kept for a long time. Both factors, viz.. the degree of dilu- 
tion necessary to eliminate the agglutinating power of non-typh : :; 
sera, as also the time-limit of observation, have been arbitrarily de- 
termine:!. WidaJ originally advised a dilution of 1 : 10. and Gruber 
a tinie-limit of one-half hour. At the present time there is a ten- 
dency, among German physicians especially, to increase the degree 
of dilution to 1 : 40. and even 1 : 50, and the time-limit to from one 
: > two hours. Generally speaking, a positive reaction is of greater 
value the greater the degree of dilution at which it can still be 
obtained. A uniform standard, however, is necessary in order 
allow a strict comparison of results, and I am personally inclined 
to favor the German standard. 

In any event, only a lull-virulent, fresh bouillon culture of the 
typhoid bacillus, viz., one not older than sixteen to twenty-four 
hours, should be used. The further technique is simple : 1 volume 
of blood-serum is diluted with the requisite amount of the bouillon 
culture, viz.. to 1 . 20, . - . . " volumes, as the standard may 
be. Of this mixture, one drop is mounted on a slide, covered, and 
examined with a moderately high power. If the case in ques:: n 
is Mie :: typhoid fever, it will be observed that after a variable 
length of time the individual bacilli, which at first actively dart 
about the field of vision, become quiescent and tend to gather in 
distinct clumps, while the interspaces become entirely free from ba- 
cilli _ nearly so. After one-half hour, or one or two hours, 
according to the degree of dilution, all motion has ceased. When 
the time-limit has expired and loss of motility and agglutination 
have not occurred the result is negative. In such an event further 
examinations should be made on the following days. In every case 
- well to make a control-test with the simple bouillon culture . - 
to insure the absence of preformed clumps and the virulence of the 
organism ; of the latter, the degree of motility is the best index. 
In m fa : -eeure the necessary degree of dilution, various nieth- 
- have been stu_ The simplest and the one generally em- 
ployed in municipal bacteriological laboratories, is to receive a large 
drop of blood upon a slide or slip of glazed paper, and allow it 
: listilled water is then placed on the blood and 
allowed to remain for several minutes, when it is washed off and 
intimately mixed with the requisite number of drops of the bouillon 
culture, and examined as described. The principal advantages of 
this method are its simplicity and the fact that the dried, blood 
retains its agglutinating properties for weeks and months. The 
less reliable than with the use of liquid blood. 
If this s to be empl perly graduated capillary pipettes are 
prepared, similar to the pipettes accompanying the Thoma-Zeiss 
hjemocytometer. Blood is first drawn up to a criven mark and 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 117 

expelled into a small watch-crystal ; the requisite amount of the 
bouillon culture is then obtained with the same pipette and imme- 
diately mixed with the blood, and a drop of the mixture is ex- 
amined under the microscope. Sterilization of the apparatus used 
is unnecessary, and each pipette is destroyed after use. 

If it is desired to keep the liquid blood for any length of time, 
similar pipettes may be used with a small bulb blown in the middle. 
These are first sterilized by heat and sealed at the ends. Before use, 
one end is broken off, the bulb heated in a spirit flame, and filled by 
capillary attraction. It is then again sealed, when the blood may 
be kept indefinitely. Another method, which is said to be even 
more reliable than those mentioned, is the following : 

After careful disinfection of the arm, 5 or 6 c.c. of blood are 
withdrawn from one of the superficial veins, by means of a sterilized 
hypodermic syringe, and placed in a sterilized test-tube measuring 
from 10 to 12 cm. in length. The blood is allowed to stand until 
the serum has separated from the clot, which may be hastened by 
loosening the coagulum from the walls of the tube wdth a platinum 
needle. Eight drops of the serum are added to 4 c.c. of nutrient 
bouillon, which should be as nearly neutral as possible, when the 
mixture is inoculated with 1 oese (platinum loopful) of a fresh 
bouillon culture of the typhoid bacillus not more than twenty-four 
hours old. The tube is kept at a temperature of 37° C. for twenty- 
four hours. At the end of this time, and frequently earlier, the 
bouillon will be absolutely clear, or very nearly so, while little flakes, 
composed of the bacilli, will be seen at the bottom and adhering to 
the sides of the tube, if the case under observation is one of typhoid 
fever ; otherwise the bouillon becomes uniformly cloudy and a 
true sediment is not formed. A pseudo-reaction also may occur at 
times, which should not be confounded with the one just described. 
Innumerable microscopical, dust-like particles w r ill then be seen 
scattered throughout the fluid, which can readily be distinguished 
from the cloudy appearance of non-typhoid specimens. It has been 
suggested that this result is obtained in cases of intense infection 
with the Bacillus coli communis. Should doubt arise, it is only 
necessary to keep such tubes for a few hours at a temperature of 
37° C, when it Avill be noticed that the dust-like aspect has given 
place to the ordinary cloudy appearance observed in cases which are 
not typhoid fever. 

Of the nature of the substance or substances which cause agglu- 
tination — agglutinins — little is known that is definite. It appears 
that in the blood they are intimately associated with fibrinogen and 
globulin, as plasma from which these two bodies have been removed 
no longer possesses agglutinating properties. As chemical differ- 
ences, however, apparently do not exist between normal globulin 
and globulin obtained from typhoid blood, it seems likely that the 



; : - the bl ; mjl 

r aces in question do not form an integral part of the globulin 

m reule, bu: - ire tin wn down mechanically when the 

| i Trid substances are p La: I_i- -■.-".-_■:-_ . . ; .. . '.-.- 

the fact that typhoid urine free from albumin may likewise anse 
arrest of motility and aggluthr: tion : tyj _oid bacillL Attempt- : 
- rate the agglutinin- from the | i :-:: Is : the blood have thus 
far not been sueces ~iuL 

The milk of iinniunized aninials or of typhoid patiente lets like 
the blood, and in it the gglutinins are apparv fly is? : vith 
casein. Ex: sure : such -" -- t< i temperature of 80° C. ■: ssb ys 
ifc __ Lutinat bag power. Very intezesting is the observation of 
Malvoz. that very dilute solutions of safianin and vesuvin act upon 
th typhoid bacilli as typhoid serum d<:»es, and upon these bacilli only. 

tAXBMATUSX — r77-:zz It." : Eyg -re". "zz. : : ~ : : - z-: Z ". I:Z- „ 

med Wociu, 1896. p. IS" r: 1 TV :-"-;_. 

and"-" . . . - ■ les H6] IS? ' "1 zl:--- IrvT. i. : !.__•- 

aDd I :•:> _-__ : Med Sri " - 7: Am. Pub. Health 

---- ~ I z:zzz. | 151 I : "7 -" - I ■■".- Hyj ~ z z - iQOL Da Cosxa. >• . Y. 
. I . Jour., 1597. Anders and McFarland. Phila. Med. Jour-, 1989. pp. 778 and s: - 

Pneumonia. 

Recent research has brought tc hght tii-E " sr _ : ~ ~. : 
in fetal cases of acute is pne th< specific ti] locoeeus 

is quite frequently present in the 1 while in ases -ending in 

very it is encountered cm! I have found, •: s 

matter of fact, that - ed in more than S 

per cent, of the filial - - TL-e iz -■■_. : :"_t ::". - . " 

occurs twenty-four t - . . - I fore death, but may take 

place at an earlier date or t I rum :__-? -Landpoint of 

sis a bade _ ical examination of the blood may thu- e 
of considerable importance. It should be remembered, how^ 
that while a ] - - ; result is always sj : »m mali ominis, there 
are cases on record in which iw axed notwithstanding 

the presence : liplococci in I •!. In such ases metastatic 

probably a eurred. I _ -zing under Eich- 

horsfs direct rts that he found pneunioeoeei in the blood in 

each of ten - - ...mined. 

reamination, which should he repeat 1 every ':'-. is conducted 
as : - f the one of the e perfic ial veins 

-- -I with & i _ .- nd punctured with . n : iinary by] - 
dermic syringe which has previ - -rerilized in trailing 

- ind agar-tubes — liquef -. wt 40* 
— I the bloocL Plates are then pre- 

pared and : mperatnre f from 31 - " : ( ~_ . The 

colonies nm 2 to 2 ud appear as small, round. _ 

jelly-like dn >ps. which are quite chara - the grc wth 

g enish discolor:.- - nher bacteria 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 119 

possess the same property, but to a less marked degree than the 
Diplococcus pneumoniae. The organism also grows on gelatin with- 
out causing its liquefaction. 

The individual organism (Plate XIV., Fig. 2) is capsulated, and 
usually occurs in pairs arranged end to end or in short chains. At 
times, however, the chains are quite long, and then it may be difficult 
to distinguish it from streptococci. It is easily stained with the 
common anilin dyes. In order to differentiate the capsule the follow- 
ing method, suggested by Welch, is best employed : spread and dried 
cover-glass preparations are treated first with glacial acetic acid, 
which is allowed to drain off, and is replaced (without washing in 
water) with anilin-gentian-violet solution. The staining solution is 
added repeatedly until all the acid is replaced. The specimen is 
now washed in a weak salt solution (about 2 per cent.), and examined 
in this, and not in balsam. The capsule and coccus can thus be 
differentiated. 

Literature.— Sittmann, Deutsch. Arch. f. klin. Med., vol. liii. p. 323. Kohn, 
Deutsch. nied. Woch., 1897, p. 136. James and Tuttle, N. Y. Presbyterian Hosp. Kep., 
vol. iii. p. 44. Goldscheider, Deutsch. med. Woch., 1892, No. 14. 

Sepsis. 

The importance of a careful bacteriological examination of the 
blood in cases of septic infection has now been established definitely. 
Large quantities of blood are, however, necessary, and reliance 
should never be placed upon a microscopical examination of a single 
drop. In doubtful cases it is best to cup the patient and to inocu- 
late agar-plates and bouillon-tubes with the serum. The animal ex- 
periment, viz., the injection of 0.5 to 2 c.c. into the peritoneal 
cavity of white mice, will also be found most valuable. 

Petruschky has shown that in severe cases of septic infection it is 
almost always possible to find streptococci in the blood, while in the 
milder cases a negative result is reached. He has found, moreover, 
that while as a general rule the presence of streptococci will justify 
a grave prognosis quoad vitam, death does not necessarily occur in 
every case. His results are tabulated below : 

Negative Results. 

Deaths. 

5 cases of puerperal fever 1 

2 " phlegmonous abscess, associated with erysipelas . . 

3 " simple erysipelas 

8 " erysipelas (convalescing) 

1 case of endocarditis 

1 " pleurisy with effusion 

1 " " with pericarditis 

2 cases of pneumonia 1 

2 " acute articular rheumatism 

1 case of scarlatina 

5 cases of typhoid fever 

7 " phthisis (in 3 of which a general pyogenic infection 

was found post mortem ; 2 streptococci ) .... 4 



120 THE BLOOD. 

Positive Kesults. 

Deaths. Recoveries. 

5 cases of sepsis, following phlegmonous abscesses, or pneu- 
monic infection (4 streptococci, 1 staphylococci) 3 2 
9 " puerperal infection (8 streptococci, 1 staphylococci) 3 6 

1 case of ulcerative endocarditis (streptococci) 1 

2 cases of mixed infection (streptococci) 1 1 

Streptococci are met with frequently in the blood after death from 
diphtheria, while the Staphylococcus aureus and Loftier' s bacillus are 
seen more rarely. In scarlatinal sepsis streptococci have likewise 
been found. 

Of other micro-organisms which may be met with in septic con- 
ditions the Diplococcus pneumoniae is the most common. It has 
been found in peritonitis, associated with carcinoma of the uterus, in 
cases of suppurative oophoritis, following childbirth, in cases of 
biliary abscess at the time of the chill, etc. Friedlander's bacillus 
has also been found. In several cases of gonorrhoeal septicaemia the 
gonococcus has been isolated during life. Proteus vulgaris has been 
found in a few instances. The Bacillus aerogenes capsulatus, which 
is so frequently seen after death, has also been obtained from the 
blood of living patients. Quite recently also a newly discovered 
micro-organism has been isolated from the blood by MacCallum and 
Hastings, which they term the Micrococcus zymogenes. It is 
apparently closely related to the pneumococcus and the Streptococcus 
pyogenes. 

The Staphylococcus pyogenes aureus occurs in the form of minute 
spherical bodies, averaging about 0.8 fi in diameter, which readily 
stain with the basic anilin dyes, as also with Gram's method. They 
usually occur in clumps, but may also be seen in pairs and in short 
chains. The organism grows on all culture-media, and in the pres- 
ence of oxygen gives rise to the formation of an orange-yellow pig- 
ment. Gelatin is rapidly liquefied ; it coagulates milk and clouds 
bouillon. The Staphylococcus pyogenes albus and citreus differ from 
the aureus by the absence of pigment in the first and by the forma- 
tion of a lemon-yellow pigment in the second. 

The Streptococcus pyogenes (Plate VII., Fig. 1) occurs in chains 
of spherical cocci which usually vary from four to twenty in number. 
The size of the individual organism is somewhat greater than that 
of the staphylococcus, but may vary even in one and the same chain. 
It is readily stained with the basic anilin dyes and also with Gram's 
method. It grows on all culture-media at the temperature of the 
room, forming small gray granular colonies on agar and gelatin. As 
a rule, it does not liquefy gelatin, and it may or may not coagulate 
milk and cloud bouillon. Several varieties are recognized, viz., 
Streptococcus brevk, which forms short chains ; Streptococcus longus, 
which occurs in long chains ; streptococci which render bouillon 



PLATE VII. 

FIG. I 

xf ,' : ' > 

J / J -•. ••. :: N 

..■-■>0 ..- "'''■■• FIG. 3. 



«G 



f "'../ :::: " 



Streptococcus Pyogenes. (Abbott.) 
FIG. 2. 




i° ' \o/fm 



QQn ' • „ /, 



Bacillus Anthraeis. highly magni- 
fied to show Swellings and Concavi- 
ties at extremities of the Single Cells. 
(Abbott, I 



-^ ^^ oo 

c8o8o8# ° 



Spirilla of Relapsing Fever 
(v. Jaksch.) 



FIG. 4. 










«f 








« 







& , 1 «* 








L. 8CHMIDT, FEC. 



Malarial Blood Stained with Chenzinsky- Plehn's Solution. 
(Personal Observation.) 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 121 

cloudy, and those which do not ; streptococci which form flocculent, 
Bandy, scaly, or viscous sediments. 

The Streptococcus conglomeratas grows, without clouding bouillon, 
in the form of dense separate particles, scales, or thin membranes 
at the bottom and sides of the tube, and on shaking the sediment 
it breaks up into little specks, without producing uniform, diffuse 
cloudiness. The chains are long aud interwoven in conglomerate 
masses ( Welch). 

LITERATURE. — F. W. White, ''Cultures from the Blood in Septicaemia, Pneumonia, 
Meningitis, and Chronic Diseases," Jour. Exper. Med., vol. iv. p., 425. W. S. Thayer and 
J. W. Lazear, " Gouorrhoeal Septicaemia and Ulcerative Endocarditis," Ibid., p. 81. 
Petruschky. Zeit. f. Hyg., vol. xvii. p. 59. Sittniaun, Deutsch. Arch. f. kliu. Med., 
vol. liii. p. 323. Canuou, Deutsch. Zeit. f. Chir., vol. xxxiii. p. 571. For compara- 
tively negative results, see Kiihuau, Zeit. f. Hyg., vol. xxv. p. 492. 

Anthrax. 

The bacillus of anthrax, as first pointed out by Pollender, Brouell, 
and Davaine, is frequently met with in the blood, where it should 
be sought for in doubtful cases by staining with Loftier' s method. 
The number of the organisms present, however, is probably always 
small. Cover-glass preparations are floated for five to ten minutes 
on a mixture of 30 c.c. of a concentrated alcoholic solution of 
methylene-blue and 100 c.c. of a 1 : 10,000 solution of potassium 
hydrate ; they are then washed for five to ten seconds in a 0.5 per 
cent, solution of acetic acid, treated with alcohol, dried, and 
mounted in balsam. Thus stained, the bacilli appear as rods meas- 
uring from 5 a to 12 /j. in length by 1 /j. in breadth, and usually 
present a segmented appearance, the extremities being slightly thick- 
ened. Spores are not found, as the organism multiplies by fission. 
When present in large numbers it is not even necessary to stain, as 
the organisms can then be s^en without difficulty in fresh specimens 
(Plate VII., Fig. 2). 

In doubtful cases, in which a microscopical examination of the 
blood yields negative results, a few cubic centimeters of the blood 
may be injected into a mouse or a guinea-pig, in the blood of which 
the bacilli will soon be found in enormous numbers if the disease 
is anthrax. 

Literature. — Pollender, Casper's Vierteljahrech. f. gerichtl. u. dffentl. Med., 1855, 
vol. viii. p. 103. Brauell, Virchow's Archiv, vol. xi. p. 132, aud vol. xiv. p. 32. Da- 
vainc Compt. rend, de l'acad. d. sci., vol. lvii. p. 220. Blumer and Young, Johns 
Hopkins Hosp. Bull., 1885, p. 127. 

Acute Miliary Tuberculosis. 

In acute miliary tuberculosis tubercle bacilli have repeatedly been 
observed in the blood ; but while their presence may be regarded as 
pathognomonic of the disease, the search for them is most tedious 
and often in vain. Nevertheless a careful examination of the blood 
is indicated in doubtful cases, but the fact should ever be borne in 



122 THE BLOOD. 

mind that only a positive result is of value. According to Lieb- 
raann, the tubercle bacilli are most numerous in the blood about 
twenty-four hours after the injection of tuberculin. Working 
in this manner, he claims to have obtained positive results in fifty- 
six cases out of one hundred and forty-one. 

For methods of staining and a description of the tubercle bacillus, 
the reader is referred to the chapter on Sputum. 

Literature. — Liebniann, Berlin, klin. Woch., 1S91, p. 393. Kronig. Deutsch. 
med. Woch., 1894, vol. v. p. 42. 

Glanders. 

In glanders the specific bacillus is constantly present in the blood, 
and may be demonstrated by staining the dried preparations on a 
cover-glass for five minutes with a concentrated alcoholic solution 
of methylene-blue, mixed with an equal volume of a 1 : 10,000 
solution of potassium hydrate just before using. From this mixture 
the specimen is passed for a second or two into a 1 per cent, solu- 
tion of acetic acid which has been tinged a faint yellow by the 
addition of a little tropseolin 00 solution ; it is then decolorized by 
washing in water containing 2 drops of concentrated sulphuric acid 



Fig. 27. 




/ 








cillus of glanders. (Abbott.) 



and 1 drop of a 5 per cent, solution of oxalic acid for each 10 c.c. 
In specimens thus stained, the bacilli appear as short rods measur- 
ing from 2 fi to 3 fi in length by 0.3 f± to 0.4 p. in breadth, often 
containing a spore at one end (Fig. 27). 

Literature.— Duval, Arch, demed. exper.. 1696, p. 361. 

Influenza. 

In the sputum of influenza a specific organism has been described 
by Pfeiffer and Kitasato ; it is said to be constantly present also in 
the blood of such patients. The organism in question appears in 
the form of minute rods measuring 0.1 a in breadth by 0.5 a in 
length occurring either singly or in chains of three or' four.' In 
suitably prepared specimens, owing to the fact that their poles take 
up the stain more readily than the middle portion, they convey the 
impression of diplococci. 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 123 

Canon advises the following method for demonstrating (heir pres- 
ence in the blood: cover-glass preparations that have been allowed 
to dry at ordinary temperature are placed in absolute alcohol for 
five minutes and are then stained at a temperature of ,'17° C. for 
from three to six hours, with Chenzinsky-Plehn's solution (see page 
101). The specimens are washed in water, dried between layers of 
filter-paper, and mounted in balsam. Stained in this manner, the 
red corpuscles are colored red, and the leucocytes, as well as the 
bacilli, blue. As a rule, only from four to twenty are found in one 
preparation, usually occurring singly, but also in groups. Owing 
to the fact that they are found in the blood only during the acme 
of the disease, Canon recommends examination of the sputum for 
diagnostic purposes, a view with which, my own observations are 
entirely in accord. Some observers indeed deny the occurrence of 
the organism in the blood altogether (Ktihnau). 

Literature. — Canon, Virckow's Archiv, vol. exxxi. p. 401. Klein, Baumgar- 
teu's Jahresb., 1393, p. 206. Ktihnau, Zeit. f. Hyg., vol. xxv. p. 492. 

Relapsing Fever. 

Relapsing fever is characterized by the presence in the blood, and 
here only, of spirilla or spirochaetae which bear the name of their 
discoverer, Obermeier. In order to search for these organisms no 
special precautions are necessary. After having carefully cleansed 
the finger, as described, a drop of blood is mounted on a very thin 
cover-glass. This is inverted directly upon the slide, when the 
specimen is ready for examination ; an oil-immersion lens is not 
required. Attention is drawn to the presence of the organisms by 
certain disturbances which are noticeable among the red corpuscles, 
and upon careful examination it will be seen that these are caused by 
the wriggling movements of the spirilla. The Spirochetal Obermeieri 
are long, slender filaments, measuring from 36 fi to 40 // in length 
by 0.3 fi to 0.5 /i in breadth, and present from eight to twelve 
incurvations of equal size with tapering extremities (Plate VII., 
Fig. 3). These last two characteristics serve to distinguish this 
Bpecies from that described by Ehrenberg, in which the radius of the 
incurvations is not the same in all, and in which the extremities do 
not taper. 

The number of spirilla which may be found in a drop of blond 
varies, being greater during the access of the fever, when twenty, or 
even more, may be observed in the field of the microscope. They 
occur singly or in bunches of from four to twenty, specimens resem- 
bling those figured in the illustration being frequently seen. In the 
quiescent stage they are arranged sometimes in the form of rings or 
of the figure 8. After the crisis they seem to disappear entirely, and 
their presence during an afebrile period may therefore be regarded as 
indicating a pseudocrisis. During the afebrile periods small, bright, 



124 THE BLOOD. 

round bodies have been described as occurring in the blood, which 
according to some are spores, but according to others represent merely 
debris of the spirilla. 

Culture-experiments have not been very satisfactory, although 
Koch observed an increase in their number at a temperature of from 
10° to 11° C. 

That confusion should ever arise in distinguishing the spirilla of 
relapsing fever from the free flagella observed at times in malarial 
blood seems to me very improbable. 

Literature. — Heidenreich. Untersuch. uber d. Parasit. d. Buckfallstyphus, Ber- 
lin, 1877. Moczutkowsky, Deutsch. Arch. f. klin. Med., vol. xxiv. p. 80, and vol. xxx. 
p. 165. Blisener, Inaug. Diss., Berlin, 1873. Engel, Berlin, klin. Woch., 1873, p. 409. 

Malta Fever. 

In Mediterranean or Malta fever the specific organism, the Micro- 
coccus melitensis (Bruce), has been isolated from the blood during 
life. Diagnosis is greatly facilitated by the fact that a well-pro- 
nounced agglutination is obtained with the patient's serum. A 
positive reaction with a dilution of more than 1 : 20, according to 
Birt and Lamb, may be regarded as proof of the existence of the 
disease. As a rule, such a result can still be reached with a dilution 
of from 1 : 600 to 1 : 700. It begins about the fifth day of the 
disease, and gradually diminishes in intensity during convalescence, 
but may persist for a year and a half, and even longer. 

Literature. — C. Birt and G. Lamb, "Mediterranean Fever," Lancet, Sept. 9, 
1899. Wright and Smith, Brit. Med. Jour., April 10, 1897. Musser and Sailer, Phila. 
Med. Jour., 1898, p. 1408, and 1899, p. 89. E. P. Strong and W. E. Musgrave, " The 
Occurrence of Malta Fever in Manila," Phila. Med. Jour., 1900, p. 996. 

Yellow Fever. 

Wasdin and Geddings, constituting a commission of medical 
officers of the U. S. Marine-Hospital Service detailed by the U. S. 
government to investigate the cause of yellow fever, report that 
Sanarelli's bacillus may be isolated from the blood of the patients 
during life. They found the organism in twelve cases out of four- 
teen after the third day of the disease, and also obtained it from 
the remaining two after death. In other diseases it was not found. 

A similar commission, consisting of Reed, Carroll, Agramonte, 
and Lazear, on the other hand, arrived at negative results. By 
withdrawing the blood from the veins of nineteen patients they 
failed to obtain a positive result in every instance. Post-mortem 
investigations in eleven cases were likewise negative. 

According to Reed and Carroll, Sanarelli's Bacillus icteroi'des 
should be considered a variety of the hog cholera bacillus, and as a 
secondary invader in yellow fever. 

Infection occurs through the bite of mosquitoes (Culex fasciatus, 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 125 

Fabr.j and probably other varieties also) which have previously fed 

on the blood of yellow lever patients. The period after contamina- 
tion which must elapse before the mosquito is capable of conveying 
the infection averages twelve days in summer, and eighteen or more 
days during the winter months. 

Literati; ke. — " Controversy between G. Sanarelli and W. Reed and J. Carroll on 
the Specific Cause of Yellow Fever," Med. News, 1899, pp. 193, 321, 513, and 737. E. 
Wasilin and H. D. Geddings, Report of Commission of Medical Officers to Investigate 
the Cause of Yellow Fever, Treasury Dept., U. S. Marine-Hospital Service, 1899. 
Reed, Carroll, and Agramonte, Jour. Am. Med. Assoc, 1901, p. 431. 

Malaria. 

The discovery in the blood of a specific micro-organism belonging 
to the class of protozoa, the Plasmodium malariw of Laveran, and 
its invariable presence in the different forms of this disease, must be 
regarded as one of the most important in clinical medicine. This is 
not the place to state how frequently a diagnosis of malarial fever 
based upon clinical symptoms alone has proved false, nor how often a 
tubercular, a syphilitic, or a septic infection has been overlooked 
and termed malaria. It will suffice to say that errors of this 
kind, in view of our present knowledge and the ease with which 
they can be avoided by every physician, should no longer occur. 
The diagnosis of malaria should in every case be based upon a micro- 
scopical examination of the blood. The search for the specific organ- 
ism, it is true, may be very tedious at times, but it will always be 
crowned with success if the disease in question is malaria. 

The parasite in question, as I have stated, is a protozoon, and 
belongs to the class of haematozoa, representatives of which are 
found in the blood of various animals, such as the rat, frog, turtle, 
carp, various birds, etc. Three varieties are known to occur in the 
blood of man, viz., the parasite of tertian, quartan, and sestivo- 
autumnal fever. The life-history of these organisms is now well 
understood, and it is known that in addition to the intra-corporeal 
cycle of development which takes place in the human body there is 
yet another, an extra-corporeal cycle, which occurs in certain mos- 
quitoes of the genus Anopheles. Infection occurs through the 
bites of such mosquitoes, which themselves have been infected by 
sucking the blood of malarial patients. This has been abundantly 
demonstrated by Ross, Manson, Grassi, and others, and may be 
regarded as an established fact. 

Method of Examination. — The necessary amount of blood is 
obtained best by puncture of a finger or the lobe of the ear, 
after this has been thoroughly cleansed with soap and water and 
dried. The first few drops are wiped away. A small drop of 
blood is then received upon a cover-glass held with a pair of 
forceps, care being taken that only the tip of the drop is touched, 
when the specimen is immediately transferred to a slide. Cover- 



126 THE BLOOD. 

glasses and slides must be absolutely clean, and it is best to keep 
both in bottles tilled with alcohol or a mixture of alcohol and 
ether. If these precautions are taken and the drop is not too large, 
the corpuscles will spread out in an even layer between the two 
glasses and retain their principal features. Pressure should always 
be avoided- For examination of the specimens an oil-immersion 
lens is almost indispensable unless the observer has been thoroughly 
trained in hematological work. If the specimens cannot be exam- 
ined at once, it is well to ring them with paraffin. They may then 
be kept for several hours. But if a longer time must elapse, it is 
necessary to prepare dried specimens, which are subsequently stained 
according to one of the following methods : 

Futcher's Method. — The air-dried films are fixed for one minute 
in a 0.25 per cent, solution of formalin in 95 per cent, alcohol. 
But as it is important that this solution should be made up fresh 
for each examination, it is more convenient to keep a 10 per cent. 
aqueous solution of formalin on hand, and to add four or five drops 
of this to 10 c.c. of a 95 per cent, alcohol just before using. The 
specimens are then rinsed in water, dried between filter-paper, and 
stained for from ten to fifteen seconds with a carbolated solution of 
thionin. This is prepared by adding 20 c.c. of a saturated solu- 
tion of thionin in 50 per cent, alcohol to 100 c.c. of a 2 per cent. 
solution of carbolic acid. The thionin carbolate thus formed con- 
stitutes the active staining principle. After washing off the ex- 
cels of stain the preparations are dried with filter-paper and mounted 
as usual. Thus prepared, the malarial parasites appear as reddish- 
violet bodies and are readily seen. The method is of special value 
in -taming the ring-shaped bodies of the a?stivo-autumnal infection, 
which are difficult to see in unstained specimens, and usually do not 
stain well with eosin and inethylene-blue. 

Staining with Eosinate of Methylene -blue. — This method has 
already been described (page 99), and, like Futcher's method, 
furnishes good results. 

Plehn's Method. — The solution employed has the following com- 
position : 

Concent rated aqueous solution of rnethylene-blue ... 60 c.c. 

solution of eo?in in 70 per cent, alcohol . . 20 c.c. 

Distilled water 40 c.c. 

Aqueous solution of sodium hydrate (20 per cent.) . . 12 drops. 

The specimen- arc fixed in absolute alcohol for from three to five 
minutes. Aiter drying they are stained for from five to six minutes, 
rinsed in water, dried between filter-paper, and mounted. The red 
corpuscles are -rained red. and the nuclei of the leucoevtes and the 
malaria] organisms blue. 

The Nocht-Romanowsky Method. — This method is employed best 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 127 

when details of structure are to In* studied in the malarial parasite. 
The cover-glass preparations are fixed by absolute alcohol, and are 
then immersed, specimen side down, for one to two hours in the 
staining solution. This should always be prepared freshly from the 

following stock solutions : 

1. .V neutral solution of Unna's polychrome methylene-blue, 
prepared by adding dilute acetic acid (2-3 per cent, solution) to the 
polychrome methylene-blue (Grubler) until the latter no longer pre- 
sents an alkaline reaction. As a general rule, 5 drops of a 3 per 
cent, solution of the acid are sufficient for 1 ounce of the com- 
mercial liquid dye. The reaction is tested with red litmus-paper, note 
being taken of the color immediately above the zone which comes 
in contact with the stain. 

2. A 1 per cent, aqueous solution of Grubler's methylene-blue, 
which should be at least one week old. 

3. A 1 per cent, aqueous solution of Griibler's watery eosin. 
The staining solution is then prepared by adding 4 drops of 

No. 3, 6 drops of No. 1, and 2 drops of No. 2 to 10 c.c. of dis- 
tilled water, mixing well. The specimens are fixed in alcohol or 
by heat, and are immersed in the stain, specimen side down, for 
one or two hours. They will not overstaiu in twenty-four hours 
(Ewing). 

Staining with Iodine. — The air-dried blood-films are exposed to 
the vapor of iodine until they assume a pronounced yellow color. 
To this end, a few grammes of iodine are placed in a small glass 
dish provided with a well-fitting top. The specimens are left in 
this dish, arranged on little glass tripods or similar contrivances, 
blood side down, for ten minutes or longer. They are then 
mounted in a drop of syrup of laevulose and examined as usual. 
Special fixation is generally not necessary, but at times specimens 
are met with in which solution of the haemoglobin takes place in 
the syrup. In such an event a brief fixation is required, for which 
purpose Futcher's formalin or absolute alcohol may be employed. 

With this method the red blood-corpuscles practically present a 
natural color more or less intensified, and the malarial organisms 
appear as in fresh blood. I have found this procedure especially 
serviceable in demonstrating the natural appearance of the parasite 
at a time when fresh blood was not available. 

The Parasite. — The following forms of the parasite may be found 
in the blood : 

1. Hyaline Non-pigmented Intracellular Bodies. — These 
apparently represent the earliest stage in the development of the 
parasite, and are found in all forms of malarial fever; they are espe- 
cially abundant during the latter part of the paroxysm or immedi- 
ately thereafter. At first sight they may be mistaken for vacuoles, 
but upon closer examination it will be found that they exhibit dis- 



128 THE BLOOD. 

tinet movement? of an anxeboid character, and may thus easily be 

_nized with a little experience. 

The rapidity with which these changes in the form of the organism 

occur in the tertian type of ague is most astonishing, and sketches 

nv one phase can often, indeed, be made only from memory; 

in quartan fever the movements are much slower and far less exten- 

- 

In the irregular fever of the a?stivo-autumnal form amoeboid 
movements may likewise be observed, but more commonly the para- 
site assumes a ring-like appearance, and does not throw out distinct 
- o dopodia. If these forms are carefully observed, however, it will 
found that they are not absolutely quiescent, but alternately ex- 
pand and contract. 

In tertian fever the organism (Plate VIII.) is pale and indis- 
tinct, while in quartan fever it is sharply outlined and somewhat 
refractive (Plate IX., Fig. 2). In the aestivo-autumnal fonn the 
organism is usually much smaller than in the tertian type, and the 
ring-like bodies frequently present at some point in their interior 
a distinctly shaded aspect which closely resembles the darker por- 
tion in the centre of a normal corpuscle (Plate IX., Fig. 1 '). It 
is thus possible, even at this stage in the development of the para- 
site, < distinguish between fever of the tertian, quartan, and a?stivo- 
autuninal type. 

The numbers in which these small, non-pigmented intracellular 
ganisms may at times be met with is most astonishing. In a case 
: pernicious malarial fever of the algid type, which I had occasion 
I xainine, and in which a history of only one week's illness with- 
out chills was obtained, normal red corpuscles were indeed only 
optionally found. The case was one of the sestivo-autuninal 
form of fever. 

2. Pigmented I^teaceleulae Oegaxisms. — These represent 
a later stage in the development of the parasite, and, like the non- 
_ rented intra cellular bodies, are met with in all types of malarial 
fever. Their appearance, however, differs considerably in the vari- 
- forms. In tertian fever minute granules of a reddish-brown 
r appear in the bodies of the organism very soon after the par- 
oxysm. These gradually increase in number, while the invaded 
corpusclt - rtionately become paler and paler, until finally only 

an indistinct, shell-like outline can be discerned. In fresh specimens 
the granules, which often assume the form of little rods, resembling 
teria, exhibit most active molecular movements, attracting atten- 
tion at once. The body of the parasite, which during its develop- 
ment has gradually in size, is probably hvaline, and may 
still be seen - o moeboid movements. These are not nearly 
s in the non-pigmented stage. The move- 
te, moreover, cannot be followed so readily, owing to the pres- 



PLATE V 



O 













L Schmidt fecit 



The Parasite of Tertian Fever 



I, Normal Red Corpuscle; 2-4. Non-pigmented Stage of the Organism, showing Amoeboid Move- 
ments- 5-7, Progressive Pigmentation and Growth; S-n, the Process of Segmentation ; 12, \oung 
Forms- 13 Large Kxtra-cellular Organism ; 14, Mode of Formation <>< Extra-cellular Body ; 15, Small 
Fragmented Extra-cellular Organism ; 16, Flagellate Body ami Free Flagella. Unstained Specimen. 
(Personal Observation.! 





PLATE IX. 

FIG. 1. 













L Schmidt feat. 

The Parasite of Aestivq-Autumnal Fever. 
i, Normal Red Corpuscle; 2-10, Gradual Growth of the Organism ; 11 and 12, Segmenting Bodies ; 
13, Young Forms ; 14-22, Crescents, Ovoids and Spherical Bodies, with and without Bib ; 23, Flagellate 
Body. Unstained Specimen. (Personal Observation.) 

FIG. 2. 





Q 






'.jnidl fecit 

The Parasite of Quartan Fever. 
1, Normal Red Corpuscle: 2-6, Gradual Growth of the Organism ; 7, Pigmented Extra-cellular Body ; 
S, Segmenting Body; 9, Young Forms; 10, Vacuolated Extra-cellular Body; it, Flagellate Form. Un- 
stained Specimen. (Personal Observation.) 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 129 

enee of the granules. At first sight, these appear to be scattered 
in small collections throughout the red corpuscle, and the impression 
may be gained that several organisms are present at the same time. 
Upon closer investigation, however, it will be seen that this is only 
apparently the ease, and that the granules are confined to the bulb- 
ous extremities of the pseudopodia of a single parasite. Before 
the end of forty-eight hours the organism has filled out the entire 
red corpuscle, which at the same time has attained a larger size 
than normal. The amoeboid movements become less and less 
marked, and the pigment-granules, which may still be quite active, 
tend to collect about the periphery (Plate VIII.). 

In quartan fever pigmented intracellular bodies likewise appear 
very soon after the paroxysm. The individual granules, however, 
[ire somewhat larger, of more irregular size, and darker in color 
than those seen in the tertian type (Plate IX., Fig. 2). Instead 
of exhibiting active molecular movements, moreover, they are 
almost entirely quiescent, and usually are grouped along the periph- 
ery of the organism. While amoeboid movements can at first 
be observed, these become less and less marked, until finally, at 
the end of from sixty-four to seventy-two hours, they cease. 
The organism then presents a round or ovoid form, but does not 
till the red corpuscle entirely. It is curious to note that in this 
form of ague the red corpuscles do not become decolorized, but 
rather darker than normally, and at times specimens may be seen 
which present a distinctly greenish or brassy appearance. When 
the parasite has become fully developed the corpuscle is smaller than 
normally, and, on staining, it may be seen that the organism still is 
surrounded by a narrow zone of corpuscular protoplasm even when 
this is not apparent in unstained preparations. 

The pigmented intracellular bodies which may be found in ?estivo- 
autumnal fever (Plate IX., Fig. 1) can readily be distinguished 
from those observed in tertian and quartan ague. As in these 
types, pigment-granules also appear after the paroxysm ; they are 
never numerous, however, and often only one or two minute dark 
granules can be detected near the periphery. The organism, even 
in the later stages of its development, scarcely ever occupies much 
more than one-third of the corpuscle. Usually the granules exhibit 
scarcely any movements. As in the quartan type of ague, decolor- 
ization of the red corpuscles does not occur, and here, as there, a 
greenish, brassy appearance often is observed. At times the red 
corpuscles are shrunken, crenated, or spiculated. 

At the beginning and during the paroxysm forms are at times 
seen in which the few pigment-granules that may be present have 
githered in the centre of the parasite and formed a solid clump. 
From the facts that these are observed only during the paroxysm, 
and that central blocks of pigment are found only during the stage 



130 THE BLOOD. 

of segmentation (see below) in tertian and quartan ague, Thayer 
and others conclude that these bodies are pre-segmenting forms of 
the parasite. This belief is strengthened further by the observation 
that pigment-bearing leucocytes are then also seen, which in the 
other types of fever likewise are found only at this time. 

3. Segmentixg Bodies. — In cases of tertian and quartan fever the 
progress of segmentation may be observed directly under the micro- 
scope, if specimens of blood are obtained just prior to or during the 
chill. In tertian fever organisms will then be seen in which the de- 
struction of the red corpuscles has advanced to a stage in which it is 
only possible to make out a pale contour of the original host. The 
parasite itself has assumed gradually a granular appearance, and the 
pigment-granules, which until then have exhibited pronounced mo- 
lecular movements, now become quiescent, larger and rounder, and 
show a distinct tendency to collect in the centre of the body. Here 
they form a roundish mass in which the individual components can 
scarcely be made out. While this change in the position of the pig- 
ment is taking place, beginning segmentation of the surrounding 
granular protoplasm will be observed. This at first is most marked 
at the periphery, from which delicate stria? will gradually be seen to 
extend toward the central mass, dividing up the protoplasm into a 
number of oval bodies which closely resemble the petals of a flower 
(Plate VIII.). Still later these bodies, which in reality are the spor- 
ules of the parasite, will be found scattered in an irregular manner 
throughout the interior of the organism. The apparent envelope 
then disappears, and the sporules, which in tertian fever usually 
number from fifteen to twenty, lie free in the blood. Quite fre- 
quently, also, a sudden expulsion of the little bodies is observed and 
the impression gained as though the envelope had been burst asunder. 
Upon closer inspection, even at the petal stage, it will be seen that 
almost every sporule presents a tiny dot in its interior, which may 
at first sight be mistaken for a pigment-granule, but which in all 
probability is a nucleus. After the expulsion of the sporules these 
are frequently seen to move about in an active manner, but sooner 
or later they come to rest. 

While the progress of segmentation is very frequently observed to 
proceed in the manner described, this is not invariably the case. It 
may thus happen that segmentation occurs before the pigment- 
granules have had time to gather at the centre, or that the parasitic 
protoplasm breaks up into sporules directly without the intervention 
of the petal stage. In every case, however, the formation of sporules 
is associated directly with the occurrence of a paroxysm, and repre- 
sents the asexual type of reproduction of the parasite. 

The ultimate fate of the sporules is not definitely known, but it is 
likely that they in turn invade new corpuscles, cause their destruc- 
tion, and become segmented, thus giving rise to a new generation. 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 131 

As the process of segmentation, moreover, coincides in time with 
the occurrence of the chill, it is apparent that the interval elapsing 
between two consecutive chills — i. c, the type of the ague — depends 
upon the rapidity with which the non-pigmented forms arrive at 
maturity. 

In quartan ague the manner in which segmentation takes place 
differs somewhat from that observed in the tertian form. It will 
here be observed that the pigment-granules, which have gathered 
along the periphery of the organism, as the parasite approaches ma- 
turity become arranged in a stellate manner, and apparently reach 
the centre through definite protoplasmic channels. Here they finally 
form a dense clump, and while the protoplasm assumes a finely 
granular appearance, segmentation proper begins and proceeds as 
in the tertian form. In quartan ague, however, the number of 
segments is smaller, varying between six and twelve. The entire 
segmenting body, moreover, is smaller than in the tertian form, and 
the segments are arranged in a more symmetrical manner. Here, 
indeed, the most perfect rosettes are observed (Plate IX., Fig. 2). 

In sestivo-autumnal fever segmenting bodies are only exception- 
ally seen in the peripheral blood, and it appears that the process of 
reproduction occurs principally in the spleen. The pre-segmenting 
forms described here undergo segmentation in a manner closely re- 
sembling that observed in tertian fever. The number of segments, 
moreover, is about the same, varying, as a rule, between ten and 
twenty. The segmenting body itself, however, is much smaller than 
in either the tertian or quartan form, and it is not possible to dis- 
tinguish any remains of the original host. 

4. Crescextic, Ovoid, and Spherical Bodies (Plate IX., 
Fig. 1). — These are observed only in cases of sestivo-autumnal fever 
when this has persisted for at least one week. At first sight they 
apparently bear no relation to the other forms wdiich have been 
de-cribed, and it has long been a question whether or not these 
bodies actually represent a stage in the life-history of the common 
malarial parasites. Grassi and Feletti have applied the name 
Laverania malarice to this form. More recent investigations have 
rendered it probable that they are derived directly from the pig- 
mented intracellular forms. Specimens may thus be met with in 
which crescentic bodies are found in the interior of red corpuscles 
that have lost but little of their original color. Such observations, 
however, are not common. The typical crescents which are usually 
seen are highly refractive bodies, somewhat larger than a red cor- 
puscle, measuring from 7 u to 9 //. in length by 2 a in breadth. 
Their extremities are usually rounded off and joined by a delicate, 
curved line bridging over their concave border. This is supposed 
to represent the remains of the original host. At other times this 
hood-like appendage is found along the convex border. The little 



IZ'A THE BLOOD. 

pigment-granules and rods, which are always found in the interior 
of the crescents, are generally collected about the centre of the 
bodv, but thev are occasionally also seen in one of the horns. While 
usuallv quiescent, a migration of some of the granules toward one 
extremity and back to the central mass may at times be observed. 
The ovoid and spherical bodies, which are usually much smaller than 
the crescents, exhibit the same general features, however, and often 
are provided likewise with a little hood. It is now known that 
the spherical bodies develop from the ovoids, and these again from 
the crescents. Like the crescents, the ovoid and spherical forms 
may be found in the interior of red corpuscles. 

5. Extracellular Pigmented Bodies. — In tertian and quar- 
tan ague some of the pigmented intracellular bodies, instead of 
undergoing segmentation when they have arrived at maturity, may 
be seen to leave their hosts and to appear as such in the blood. At 
the same time they increase considerably in size, and in the tertian 
form may indeed become as large as a poly nuclear leucocyte (Plate 
VIII. ). The pigment-granules, moreover, exhibit an activity iu 
their movements which is most astonishing and never observed 
under other conditions. The outline of the parasite is then usually 
irregular and quite indistinct. Upon careful observation it will be 
seen that in some of these bodies the movements of the granules 
after a while become less and less marked, and finally cease, while 
the body of the parasite itself becomes still more irregular in out- 
line. This appearance is undoubtedly referable to the death of the 
organism. In others a gradual fragmentation is observed, small 
particles of the pigmented mother-substance being cut off from the 
parent-form. It is thus quite common to see the original parasite 
break up into four or five smaller bodies, in which the movements 
of the pigment-gra miles persist for some time. Sooner or later, 
however, even these cease, the outlines of the bodies become more 
and more indistinct, and death occurs. In still others the forma- 
tion of vacuoles may be observed, the pigment-granules at the same 
time becoming quiescent. This process is likewise regarded as one 
of degeneration. Most interesting, however, is the fact that flag el- 
frtion may occur in some of these extracellular forms. It will then 
be observed that the pigment-granules which exhibit a most sur- 
prising activity tend to collect near the centre of the organism, 
while at the same time curious undulating movements may be made 
nut along its contours. Suddenly one or more (one to six) extremelv 
slender filaments will be seen to protrude from as manv points on 
the periphery, presenting minute enlargements here and there in 
their course (Plate VIII. ). The length of these filaments, or fla- 
gella. as they are termed, varies considerably. As a rule, it does not 
exceed the diameter of from five to eight red corpuscles, but much 
longer specimens are at times observed, and it appears to me that 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 133 

in most illustrations they arc represented too short. With these 
flagella the organism exerts most active whipping movements, scat- 
tering the rod corpuscles to the right and left. Attention is, indeed, 
usually first drawn to the presence of these bodies by the disturb- 
ance which they cause in the held of vision. Occasionally one of 
the flagella may be seen to become detached from the body of the 
parasite and to move rapidly about among the corpuscles in a snake- 
like manner. In microscopical specimens they gradually come to 
a rest and often curl into a spiral. That difficulty should ever arise 
m distinguishing such detached flagella from the spirilla of relapsing 
fever seems very improbable, as the nature of these formations is 
shown by the presence or absence of other forms of the malarial 
organism. 

Beyond the fact that the flagellate organisms in tertian fever are 
larger than in the quartan form, no special points of difference exist 
(Plate IX., Fig. 2). 

In sestivo-autumnal fever similar changes may be observed. In 
crescents it is thus not at all uncommon to observe a small hyaline 
protrusion from the surface of the organism, which later may 
become detached. This process was formerly regarded as one of 
regeneration, but it is questionable whether this is actually the case. 
In other specimens, again, true fragmentation, or vacuolization, may 
occur, and flagellate bodies are met with in this type of fever as 
well as in tertian and quartan ague. The flagellates, as in quartan 
fever, are smaller than those observed in the tertian form, but other 
points of difference do not exist (Plate IX., Fig. 1). 

The significance of the flagellate organisms has until recently 
not been understood, but we now know that they represent the 
male element in the sexual reproduction of the malarial parasite, 
and the beginning of a cycle of development, which takes place 
outside of the human body, in the bodies of certain mosquitoes. 
The beginning of this cycle was observed first by MacCallum in the 
blood of infected crows. He here discovered that when one of the 
flagella broke loose it almost always sought out another full-grown 
form of the parasite which had not undergone segmentation, and 
penetrated this, just as the spermatozoon penetrates the ovum. 
Subsequently he observed the same process in the blood of the 
human being. The further development of the fertilized forms, 
however, does not take place in the human blood, but in the bodies 
of mosquitoes. The fertilized organism then penetrates the stomach- 
wall of the insect, and here gives rise to the formation of little 
c\>ts, in which after about seven days numerous irregular, rounded, 
ray-like striae appear. After a time the capsules of the cysts burst, 
and the delicate, thread-like bodies [ire set frvv in the body cavity 
of the mosquito, and shortly after appear in the salivary glands. 
These bodies apparently represent the young parasites, which result 



134 TEE BLOOD. 

from the sexual reproduction of the adult organism. If at this 
stage of their development the infected mosquito is allowed to bite 
a human being, malarial infection results, with the appearance in 
the blood of the hyaline forms already described. 

From the above description it will be seen that three forms of 
the malarial parasites may be found in the blood, viz. . the parasite of 
tertian, quartan, and a^stivo-autumnal fever, and it has been shown 
that these forms may readily be distinguished from each other. 
It should be mentioned, however, that in tertian and quartan fever 
several groups of the same organism may be present at one time, 
and as the pr 3ess : segmentation coincides with the occurrence of 
a paroxysm, it will readily be seen that the number of paroxysms 
within a given time depends directly upon the number of groups 
which may be present in the blood. If a double infection with the 
tertian parasite has occurred, one group of organisms may thus have 
just reached the segmenting stage, while the second group has atr- 
tained only a twenty-four hours' growth, the result being that maturity 
is reached by the two groups on successive days. Quotidian fever 
is then the result. Should still other groups be present, the clinical 
picture will accordingly become more complicated. In quartan 
ague, similarly, double quartan fever will occur if two groups are 
present, and triple quartan fever if three groups are present at one 
time. Mixed infections, further, are also possible. 

In conclusion, it may not be out of place to refer to the presence 
of piginent-bearing leucocytes in the blood of malarial patients. 
These are quite constantly met with during the paroxysm, and it is 
indeed often possible to observe the process of phagocytosis directly 
under the microscope (see Fig. 15). The forms which are taken up 
are the central pigment-clumps of organisms that have onderg ue 
sporulation, the small, fragmented extracellular forms, the flagellate 
bodies, and even the segmenting bodies. In every case where pig- 
ment-bearing leucocytes — which are probably always of the neu- 
trophilic, polynnclear variety — are observed malarial fever should 
be suspected and a careful examination made, as a melana?mia 

only in this disease, in relapsing fever, and in 
connection with the rare melanotic tumors, in which not only leuco- 
cytes containing melanin occur in large numbers, but also masses of 
this pigment float free in the blood. 

Literature. — A. Laveran. Nature parasitaire des accidents de rinipaludisme, 

•i d*un nouveau parasite, Pari?. 1881. Fur a full account of the literature, 

see: sxaphbyW. 8 .1 J. Hewetson, " The Malarial Fevers of Balti- 

mon On recent advances in our knowledge 

fever, see W. S Thayer. Phila. Med. Jour., 1900, 
P- 10* : the literature is given. T. B. Futcher. " A Critical 

Summary Literature concerning the Mosquito as an Asrent in the Traus- 

•n of Malaria," Am. Jour. Med S - , p. 318. W. S. MacCallum. "On the 

Ham n of Birds." Jour. Exper. Med., vol. iii. p. 117. E. L 

the Haematozoon of Birds. Ibid., p. 79. F. Grohe. Zur Gesch. d. Melanaemie, Vir- 
chow's Archiv, 1861, vol. xx. p. 306. 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 135 

Filariasis. 

Filaria sanguinis hominis (Lewis) : si/n., Filaria Wuohereri (da 
Silva Lima) ; Filaria Bancrofti (Cobbold) ; Filaria Mansoni ; Trichina 
cystica (Salisbury); Trichina sanguinis hominis aocturna (Manson). 

Several varieties of the parasite (Fig. 28), which belongs to the 
class of nematodes, have been observed in the blood of man. Among 
these arc the Filaria sanguinis hominis nocturna, Filaria sanguinis 
hominis diurna, or Filaria sanguinis hominis, var. major, and Filaria 
sanguinis hominis, var, minor. 

The female of Filaria nocturna, according to Manson's description, 
is "a long, slender, hair-like animal, quite three inches in length, 
but only one one-hundredth inch in breadth, of an opaline appear- 
ance, looking as it lies in the tissues like a delicate thread of catgut, 
animated and wriffffline. \ narrow alimentarv canal runs from 

of? o J 

the simple elub-like head to within a short distance of the tail, the 

Fig. 28. 




Filaria sanguinis hominis, showing sheath. (After Lewis.) 



remainder of the body being almost entirely occupied by the repro- 
ductive organs. The vagina appears about one twenty-fifth of an 
inch from the head ; it is very short, and bifurcates into two uterine 
horns, which, stuffed with embryos in all stages of development, run 
backward nearly to the tail " (Osier). The male worm is rarely 
seen, and is much smaller than the female. While the adult parasite 
has its habitat in the lymphatic channels, the embryos, which are set 
free in enormous numbers, invade the blood-current, in which they 
may readily be found at night ; during the day an examination of 
the blood will usually yield negative results. This periodicity may, 
however, be reversed by having the patient sleep in the daytime and 
be about at night. Each embryo has an envelope of its own, which 
is hyaline in appearance, and within which the young worm, measur- 
ing 0.34 mm. in length by O.OOTo mm. in breadth, is able to extend 
and contract itself. In fresh preparations these organisms are readily 
detected by the disturbance with their movement- create among the 
corpuscles; they are apparently transparent and homogeneous, but 



136 THE BLOOD. 

after some time, when the worm has come to rest, it will be seen that 
they are granular and transversely striated. 

As the mere presence of these parasites usually does not produce 
symptoms, and as an examination of the blood made in daytime, 
as already stated, generally yields negative results, attention is 
drawn to their presence only when symptoms pointing to an 
occlusion somewhere in the course of the lymphatic channels 
exist, as evidenced by chyluria (which see), elephantiasis, or lymph 
scrotum. 

Infection occurs through the bite of certain mosquitoes, viz., 
Anopheles, Culex penicillarius, and Culex pipiens. The develop- 
ment of the different forms seems to take place in different organs 
of the host. 

The Filaria perstans is a variety which Manson found in the 
natives of the western coast of Africa. Its embryos are found in 
the blood both during the day and at nights. They have no sheath 
and are actively motile. 

Literature. — Mosler and Peiper, Specielle Path. u. Therap., 1894, vol. vi. p. 219, 
P. Manson, Allbutt's System of Medicine, vol. ii. I. Guiteras, Med. News, April, 
1886. F. P. Henry, Ibid., 1896. E. Opie, Am. Jour. Med. Sci., 1901, vol. cxxii. p. 251. 



Distomiasis (Bilharziosis). 

Bilharzia hsematobia (Cobbold) : syn., gynsecophorus (Diesing) ; 
Distomum haematobium (Bilharz) ; Schistosoma haematobium (Wein- 
land) ; Distoma capense (Harley) ; thecosoma (Maguin-Tandon). 

The Bilharzia hsematobia belongs to the class of trematode pla- 
todes. According to Bilharz, the greater portion of the Fellah 
and Coptic population of Egypt is infected. It is abundant also in 
South Africa, and is now said to occur occasionally in the United 
States. From Europe no cases have as yet been reported. It may 
give rise to diarrhoea, hematuria, and ulceration of the mucous 
surfaces. 

The male is smaller but thicker than the female, measuring from 
12 to 14 mm. in length ; on its abdominal surface a deep groove is 
found with overlapping edges, which serves for the reception of the 
female (Fig. 29). 

While the adult parasite is seen but rarely in the blood, its ova 
are found frequently. These are slender bodies, measuring 0.12 
mm. in length by 0.04 mm. in breadth, and are provided with a dis- 
tinct, spike-like projection, which issues from one extremity or the 
side. Infection apparently takes place through unfiltered drinking- 
water. 

LITERATURE.— Bilharz, Wien. med. Woch.. 1856, vol. vi. p. 49. Meissner, Schmidt's 
Jahrbiich., 1882, vol. xxx. p. 193. Eiitimeyer, Verhandl. d. Cong. f. inn. Med., 1892, 
vol. xi. p. 144, 



BACTERIOLOGY AND PARASITOLOGY OF THE BLOOD. 137 

Fig. 29. 




Male and female specimens of the human blood fluke {Bilharzia hxmatobia) , enlarged. X 12. 

(After Looss.) 

Anguilluliasis. 

Of late, Teissier has announced that in a case of intermittent 
fever numerous embryos of anguillula were found in the blood. 
They disappeared after expulsion of the parasites from the intestinal 
tract, and at the same time the fever ceased (for a description of 
the anguillula, see page 251). 

Literature. — Teissier, Compt. rend, de l'acad. des sci., vol. cxxi. p. 171. 



CHAPTER II. 
THE SECRETIONS OF THE MOUTH. 

SALIVA. 

Normal, saliva is a mixture of the secretions derived from the 
submaxillary, sublingual, parotid, and mucous glands of the mouth. 
It is a colorless, inodorous, tasteless, somewhat stringy and frothy 
liquid, and serves the purpose of aiding in the acts of mastication, 
deglutition, and digestion. The quantity secreted in twenty -four 
hours amounts to about 1500 grammes. 

General Characteristics. 

Xormal saliva has a specific gravity of from 1.002 to 1.009, cor- 
responding to the presence of from 4 to 10 grammes of solids. The 
reaction of the saliva proper is alkaline, the degree of alkalinity 
corresponding to from 0.006 to 0.048 per cent, of sodium hydrate. 
Normally an acid saliva is observed only in newly born infants and 
in sucklings. 

The reaction of the tongue and the mucous membrane lining the 
mouth is quite commonly acid early in the morning, owing to the 
production of lactic acid by some of the bacteria which are constantly 
present in the mouth. This acid, according to Magittot, corrodes 
the enamel of the teeth, and may ultimately produce dental caries. 

Chemistry of the Saliva. 

In order to give an idea of the general composition of the saliva 
the following analyses are appended ; the figures correspond to 1000 
part- by weight : 

Water . 995.20 994.20 988.10 

Ptyalin 1 1.34 1.30 1.30 

EpwTelium} L62 2.20 2.60 

Fatty matter . . 0.50 

Solphocyanides 0.06 0.04 0.09 

Alkaline chlorides 0.84 

: hate 0.94 2.20 3.40 

Magnesium and calcium salts . . 0.04 

Alkaline carbonates traces. 

1 These figures are too high, as they refer to the total precipitate ohtained with 
alcohol. 



SALIVA, 139 

In order to demonstrate the presence of the sulphocyanides, it is 
usually only necessary to heat a few cubic centimeters of the pure 
saliva, faintly acidified with hydrochloric acid, with a dilute solution 
of ferric chloride, when a red color will be seen to develop. If 
necessary, larger quantities, such as 100 c.c., are evaporated to a 
small volume ; the test is then applied to the concentrated fluid. 

Of organic matter, ptvalin, a little albumin mixed with mucin, 
and about 1 gramme of urea pro liter are found. Of all these sub- 
stances, the ptyalin is especially interesting from a physiological 
point of view. It may be isolated in a comparatively pure state 
according to Gautier's method : 

To a large quantity of saliva alcohol (98 per cent.) is added as 
long as a flocculent precipitate forms. This is collected upon a small 
filter and dissolved in a little distilled water. The solution thus 
obtained is treated with several drops of a solution of mercuric 
chloride, in order to remove albuminous material, which is filtered 
off. The excess of mercury is removed by means of hydrogen 
sulphide, when the remaining liquid is evaporated at a temperature 
of from 35° to 40° C, and taken up with strong alcohol. The in- 
soluble residue is dissolved in a little water, filtered, dialyzed in 
order to remove inorganic salts, and is finally precipitated with 
strong alcohol, when the ptvalin will separate out in light flakes. 
Obtained in this manner, ptyalin is a white amorphous substance, 
soluble in water, dilute alcohol, and glycerin. In neutral or even 
slightly alkaline solutions, but not in acid solutions, it rapidly 
transforms boiled starch into dextrin and sugar at a temperature 
of from 35° to 40° C. This transformation takes place according 
to the equations : 

(1) (C 12 H 20 O 10 ) 54 + 3H 2 = 3[(C 12 H 20 O 10 ) 17 .C 12 H 22 O n ]- 

Starch. Erythrodextrin. 

(2) 3[(C 12 H 20 O 10 \ 7 .C 12 H 22 O n ] + 6H 2 = ^(C^O^.C^AJ. 

Erythrodextrin. Achroodextrin 

(3) 9[(C 12 H 20 O I0 ) 5 .C 12 H, J () u ] - 45H 2 = 54C 12 lI 22 O n = 54C l2 H 22 O n . 

Achroodextrin. Isomaltose. Maltose. 

In order to test far ptyalin, a few cubic centimeters of saliva are 
filtered and added to a solution of starch ; the mixture is placed in 
the warm chamber for some time, when it is tested with cupric sul- 
phate or iodine. At first, starch gives a blue color with iodine ; 
after the reaction has proceeded further a red or violet-red color is 
obtained, indicating the presence of erythrodextrin, while no change 
in color at all results when achroodextrin only is present. The 
maltose may be recognized by the fact that it turns the plane of 
polarization more strongly to the right than glucose ; it also reduces 
Fehling's solution. 

The test far nitrites, which may likewise be present in the saliva, 
is conducted in the following manner : about 10 c.c. of saliva are 



140 



THE SECRETIONS OF THE MOUTH. 



treated with a few drops of Ilasvay's reagent and heated to a tempera- 
ture of 80° C, when in the presence of nitrites a red color will 
develop. The reagent is prepared as follows : 0.5 gramme of sulph- 
anilic acid in 150 c.c. of dilute acetic acid is treated with 0.1 
gramme of naphtylamin dissolved in 20 c.c. of boiling water. After 
standing for some time the supernatant fluid is poured off and the 
blue sediment dissolved in 150 c.c. of dilute acetic acid. The solu- 
tion is kept in a sealed bottle. 



Microscopical Examination of the Saliva. 

If normal saliva is allowed to stand, two layers will be seen to 
form, viz., an upper clear and a lower cloudy layer, which latter con- 
tains certain morphological elements. Among these, salivary cor- 
puscles, pavement epithelial cells, and micro-organisms are found 
(Fig. 30). 

Fie. SO. 







°\o*F'\* •" 



•• k 




Buccal secretion. (Eye-piece III., obj. Reichert, ^ homogeneous immersion : Abbe's 
mirror, open condensers.) a, epithelial cells; b, salivary' corpuscles ; c, fat-drops; d, leuco- 
cytes ; e, Spirochseta buccalis ; /, comma-bacillus of mouth; g, Leptothrix buccalis; h, i, k, 
various fungi, (v. Jaksch.) 

The salivary corpuscles resemble white corpuscles very closely, 
but differ in their greater size and coarser appearance. The epi- 
thelial cells are large, irregular, polygonal cells, provided with well- 
defined nuclei and nucleoli ; they exhibit certain irregularities in 
size, according to their origin, and belong to the class of pavement 
or stratified epithelium. 

Micro-organisms. 1 — While schizomycetes and moulds are only 
exceptionally found in the mouth under normal conditions, and are 
then undoubtedly derived from ingested food, bacteria are always 
present in largo numbers, and it is not surprising that all forms 
which are found in the air, food, and drink may here be encountered 
(Plate X., Fig. 1). Some of these, such as the Leptothrix buccalis 
innominata, Bacillus buccalis maximus, Leptothrix buccalis maxima, 

1 W. D. Miller, Die Mikroorganismen d. Mundbohle, 1892. 



PLATE X. 



FIG. 1. 



t "^V> 



9mM 



Bacteria of the Mouth. (Cornil Babes.) 



FIG. 2. 




Leptothrix Bueealis. v. Jakseh.) 



SALIVA. 141 

Iodocoocus vaginatus, Spirillum sputigenum, and Spirochete den- 
tium, arc always present. Together with other bacteria, they have 
been found in carious teeth, in abscesses communicating with the 
mouth and pharynx, and in exudates on the mucous membranes of 
these parts. In all probability, however, they are non-pathogenic. 
To this class also belongs the smegma bacillus, which has been en- 
countered in the saliva, the coating of the tongue, and in the tartar 
of the teeth of perfectly healthy individuals. In this connection it 
is interesting to note that, in contradistinction to the bacteria which 
are only temporarily found in the mouth, the majority of those 
which are constantly present cannot be cultivated on artificial media. 

Important from a practical standpoint is the fact that a number 
of pathogenic micro-organisms may at times be found under normal 
conditions. The Diplococcus pneumonia?, also known as the pneu- 
mococcus of Friinkel and Weickselbaum, the Diplococcus lanceolatus, 
the Micrococcus lanceolatus, the Micrococcus septicaemia? sputi, and 
the Micrococcus pneumonia? cruposa? (Sternberg), has thus been found 
in a virulent condition in from 15 to 20 per cent, of healthy indi- 
viduals, and it is even claimed that in a non-virulent state it is 
constantly present in the mouth. Streptococci are likewise frequently 
observed, but usually possess but little virulence or none at all 
when obtained from the healthy mouth and tested upon animals. 
Pyogenic staphylococci may also be found at times, but are less 
common than the streptococci. Most important is the occasional 
occurrence of the diphtheria bacillus in the mouths of individuals 
who have not been exposed to contagion. Welch l mentions that 
virulent organisms were found by Park and Beebe in the healthv 
throats of eight out of three hundred and thirty persons in New 
York, who gave no history of direct contact with cases of diphtheria. 
Two of these eight persons later developed the disease. Non-virulent 
bacilli were found in twenty-four individuals of the same series, and 
the pseudodiphtheria bacillus in twenty-seven. 

Other pathogenic bacteria which may be found in normal mouths 
are the Micrococcus tetragenus, the Bacillus pneumoniae of Fried- 
lander, the Bacillus crassus sputigenus, and the Bacillus coli com- 
munis. 

It is interesting to note that the secretions of the mouth and 
throat, as most secretions of the body, possess a certain degree of 
germicidal power. The Staphylococcus aureus, the Streptococcus 
pyogenes, the Micrococcus tetragenus, the typhoid bacillus, and the 
cholera spirillum, when present in moderate numbers, are thus 
killed by the saliva. The diphtheria bacillus, however, is more 
resistant, and may survive for twenty-four to forty days. It has 
been found, as a matter of fact, that the organism may be demon- 
strated in the throats of some individuals who have passed through 

1 Dennis' System of Surgery : Surgical Bacteriology. 



142 THE SECRETIONS OF THE MOUTH. 

an attack of diphtheria for several weeks after all the clinical symp- 
toms have disappeared. The Diplococcns pneumoniae is even said 
to grow well in saliva, although it rapidly loses its virulence. By 
then cultivating it upon pneumonic sputum, however, the virulence 
of the organism is restored. The individual bacteria will be con- 
sidered in detail later on. 



Pathological Alterations 

It has been mentioned that about 1500 grammes of saliva are 
secreted in the twenty-tour hours. This quantity is, however, sub- 
ject to great variation. An increase is thus frequently noted in 
pregnancy, in various neurotic conditions, in tabes, bulbar paralj - - 
in inflammatory diseases of the mouth, in dental caries, following 
the administration of piloeai-pin, in poisoning with mercury, acids, 
and alkalies, etc. The quantity is diminished in all febrile diseases^ 
in diabetes, and often in nephritis. The effect of psychic influences 
upon the secretion of saliva as well as of other glands is well 
known, an increase or decrease in the flow being produced under 
various conditions. 

In determining whether or not salivation actually exists, the physi- 
cian should not only be guided by the statements of his patients, 
but an actual estimation of the amount secreted within a definite 
period of time should be made. Hysterical individuals not infre- 
quently complain of "salivation/' when a direct estimation will 
show that the amount is not only not increased, but actually dimin- 
ished. 

An acid reaction of the saliva has been noted in various diseases 
of the intestinal tract, in febrile diseases, and notably in diabetes 
(Frerichs)). According to Strauss and Cohn, however, an alkaline 
reaction of the saliva is the rule even under pathological conditions. 

Among the qualitative changes may be mentioned an increase in 
the amount of urea, which has been repeatedly observed, and especi- 
ally in nephritis. 

Urea may be demonstrated as follows : the saliva is extracted 
with alcohol, the filtrate evaporated, and the residue dissolved in 
amyl alcohol. This is allowed to evaporate spontaneouslv, when 
crystaL? of urea will separate out, and may then be examined micro- 
scopically and chemically Ksee Urin 

Bile-pigment and sugar have not been found in the saliva. 

Of drugs, - .urn iodide and potassium bromide rapidly pass 

into the saliva. Upon this property the indirect examination of the 
ga-tric juice for its digestive power — i. e., the presence or absence 
of free hydrochloric acid — by means of the potassium iodide and 
fibrin packages of Gunzburg, is partly based. 

In order to test for potassium iodide, strips of filter-paper moist- 



SPECIAL DISEASES OF THE MOUTH. 1 13 

ened with starch solution are immersed in the saliva, which has 
been acidified with nitric acid ; in the presence of potassium iodide 
the starch-paper turns blue. 

SPECIAL DISEASES OF THE MOUTH. 

Tuberculosis of the Mouth. — In cases of lupus and the so-called 
benign form of tuberculosis of the mouth it is rarely possible to 
demonstrate the presence of tubercle bacilli, even in scrapings taken 
from the base of the ulcers or in the diseased tissue itself, while in 
eases of ulcerative stomatitis associated with phthisis in its advanced 
stages they may be frequently found in large numbers. In some 
cases, however, their demonstration is by no means easy. In the 
saliva they are only exceptionally seen. 

Actinomycosis. — In cases of actinomycosis it is occasionally pos- 
sible to demonstrate the presence of the specific organism in or about 
carious teeth. More commonly, however, the patients are not seen 
until the primary symptoms of the disease have disappeared, when 
the typical kernels can no longer be found at the original points 
of entry or have become unrecognizable owing to calcification and 
retrogressive changes. 

Usually the disease has already progressed to the formation of a 
distinct tumor or abscess, and it may then be necessary to make an 
exploratory incision, and to examine the scrapings which are brought 
away. The number of kernels which may be found is at times very 
small, but a careful examination will probably always lead to their 
detection if the disease in question is actinomycosis. 

Catarrhal Stomatitis. — In this affection the quantity of saliva 
is increased. Microscopically an increased number of epithelial 
cells and many leucocytes are noted, their number depending upon 
the intensity of the morbid process. 

Ulcerative Stomatitis. — In this condition, following mercurial 
poisoning or scurvy, the same appearance is noted microscopically 
as in simple stomatitis. In addition there may be necrotic tissue, 
red blood-corpuscles, and innumerable leucocytes. The reaction of 
the saliva is intensely alkaline, the color markedly brown, and its 
odor fetid. 

Gonorrhceal Stomatitis. — The number of cases of gonorrboeal 
stomatitis that have thus far been recorded is small. The disease, 
however, has received but little attention, and is probably more 
common than is generally supposed. In the adult it may be con- 
tracted through coitus contra naturam, while in the newborn the 
infection is undoubtedly brought about in the same manner as the 
corresponding disease of the conjunctiva. In suspected cases the 
exudate which forms upon the gums, the tongue, and the palate 
should be examined for the presence of gonococci. In adults the 



144 



THE SECRETIONS OF THE MOUTH. 



organism has thus far not always been found ; in the newborn, 
however, Rosinski has succeeded in demonstrating its presence in 
all cases examined. 

Thrush. — Oidium albicans (Fig. 31) is most commonly seen in 
children, but may also occur in adults, and especially in phthisical 
individuals, and sometimes lines the entire mouth. If in such cases 
a bit of the membrane is pulled off and examined microscopically, it 
will be found to consist of epithelial cells, leucocytes, and granular 
detritus, with a network of branching, band-like formations, which 




Oidium albicans, the vegetable parasite of muguet or thrush. (Reduced from Ch. Robin.) 

present distinct segments. The contents of the segments are clear, 
and usually contain two highly refractive granules — the spores, one 
of which is situated at each pole. These segments diminish in size 
toward the end of each band, their contents at the same time becom- 
ing slightly granular. 

TARTAR. 

In a bit of tartar scraped from the teeth actively moving spiro- 
chaetse are seen, as well as long, usually segmented bacilli, frequently 
forming bands which are colored bluish red by a solution of iodo- 
potassic iodide. Leptothrix buccalis, shorter bacilli (which are not 
colored by this reagent), micrococci, and a large number of leuco- 
cytes and epithelial cells which have undergone fatty degeneration, 
are also found. 

COATING OF THE TONGUE. 

A brown coating of the tongue is often observed in severe infec- 
tious diseases, and consists of remnants of food and incrustated blood. 
Microscopically, in addition to a large number of epithelial cells, 
enormous numbers of micro-organisms and a large number of dark, 
cell-like structures, probably derived from desquamated epithelial 
cells, are found. The white coating of the tongue contains epithelial 
cells, many micro-organisms, and a few salivary corpuscles. 



COATING OF THE TONSILS. 145 

COATING OF THE TONSILS. 

Pharyngomycosis Leptothrica. 

In the props from the crypts of the tonsils in cases of follicular 
tonsillitis, and also in persons who have had frequent attacks of ton- 
sillitis, according to Chiari, epithelial cells and long, segmented 
fungi — the Leptothrix buccalis (Plate X., Fig. 2) — which are col- 
ored bluish red by a solution of iodo-potassic iodide, are seen. At 
times patches composed of these fungi extend over a considerable 
area of the tonsils, so that it may be doubtful whether or not the 
disease is a beginning diphtheria. A microscopical examination will 
in such cases settle all doubts. 

Tonsillitis. 

In tonsillitis a large number of bacteria have been isolated from 
the pseudomembranous deposits. Among the more important which 
are supposed to bear a causative relation to the disease may be 
mentioned the various streptococci, staphylococci, less commonly the 
pneumococcus, the diplococcus of Brison, the Bacillus coli communis, 
the bacillus of Friedlander, the Bacillus septicaemiae sputi, and in a 
few isolated instances the Micrococcus tetragenus. In many cases 
in which tonsillar deposits were clinically regarded as diphtheritic 
culture revealed only an abundance of the thrush fungus. 

Glandular Fever. 

According to Neumann and Corn by, glandular fever generally 
depends upon infection with a streptococcus. In the cases reported 
by Lande and Froin and by Hirtz l bacteriological examination of 
the throat at the height of the febrile stage revealed the presence of 
the pneumococcus in a virulent condition. 

Diphtheria. 

Recognizing the great importance of an early diagnosis in such a 
malignant disease as diphtheria, an examination for Loffler's bacillus 
has become just as important to-day as that for the bacillus of tuber- 
culosis, and every physician should make himself familiar with the 
methods employed for its recognition. 

By means of a sterilized, stout platinum loop, a pair of forceps, 
or a cotton swab, a piece of membrane is scraped from the tonsils, 
the soft palate, or the pharynx, and at once transferred to n sterilized 
test-tube closed with a pledget of cotton. A particle of the mem- 
brane is then spread in as thin and uniform a layer as possible upon 
a cover-glass. When dry the specimen is fixed by being passed 

1 Lande et Froin, Rev. mensuelle des Mai. de l'Eufance, 1901, p. 78. 
10 



146 THE SECRETIONS OF THE MOUTH. 

through the flame of a Bunsen burner three or four times, when it 
is ready for staining. For this purpose Loffler's alkaline solution 
of methylene-blue, which consists of 30 c.c. of a concentrated alco- 
holic solution of methylene-blue in 100 c.c. of an aqueous solution 
of potassium hydrate (1 : 10,000), may be advantageously employed, 
the specimen being stained for from five to ten minutes. It is then 
rinsed in water, placed on a slide, the excess of water removed with 
filter-paper, and examined with a one-twelfth oil-immersion lens. 

A dahlia-methyl-green solution may likewise be employed. This 
consists of 10 grammes of a 1 per cent, aqueous solution of dahlia- 
violet and 30 grammes of a 1 per cent, aqueous solution of methyl- 
green. The specimen is stained for from one to two minutes. 

If it is desired to employ Gram's method, the specimen is most 
conveniently stained for three minutes with a freshly prepared con- 
centrated alcoholic solution of gentian-anilin water. This is pre- 
pared by adding anilin oil to 10 c.c. of distilled water, drop by 
drop, thoroughly shaking after the addition of each drop, until the 
solution becomes opaque. It is then filtered and treated with 10 c.c. 
of absolute alcohol and 11 c.c. of a concentrated alcoholic solution 
of gentian-violet. The specimen is decolorized in a solution com- 
posed of 1 gramme of iodine and 2 grammes of potassium iodide, 
dissolved in 300 c.c. of water. After remaining in this solution for 
five minutes the specimen is rinsed in alcohol and the process repeated 
until the violet color disappears. It is transferred to absolute alco- 
hol, then to oil of cloves, and mounted in balsam. 

Cultures should also be made, preferably upon a mixture of blood- 
serum and bouillon, as recommended by Loffler. This is composed 
of three parts of blood-serum and one part of bouillon, containing 
10 per cent, of peptone, 3 per cent, of grape-sugar, and 0.5 per cent, 
of sodium chloride, the mixture being solidified in the usual manner. 
Upon this medium Loffler' s bacillus grows so much more rapidly 
than other organisms which are usually present in the secretions of 
the mouth and throat, that at the end of twenty-four hours they 
often form the only colonies that attract attention. Should other 
colonies of similar size be present, these are generally quite different 
in appearance. In this manner a diagnosis can be made upon the 
day following inoculation of the tube. 

In the absence of blood-serum bouillon, alkaline bouillon, nutrient 
gelatin, nutrient agar, glycerin-agar, and potato may be employed. 
Coagulated egg-albumin, as pointed out by Booker, and milk are 
also good soils. 

The colonies are large, round, elevated, and grayish-white in 
color, with a centre that is more opaque than the slightly irregular 
periphery. The surface of the colony is at first moist, but after a 
day or two assumes a dry appearance. 

The bacillus (Fig. 32) is non-motile and varies in size and shape, 



COAT IS G OF THE TONSILS. 147 

its average length being from 2.5 //. to 3 //, its breadth from 0.5 // to 
0.8 n. Its morphological characteristics are so peculiar as to render 
its identification upon cover-slip preparations and in sections of the 
diphtheritic membrane an easy matter in most cases. 

Sometimes the organism appears as a straight or slightly curved 
rod ; but especially characteristic are irregular and often bizarre 
forms, such as rods with one or both ends terminating in a little 
knob, and rods broken at intervals, in which short, well-defined, 
round, oval, or straight segments can be made out. 

Some forms stain uniformly, others in an irregular manner ; the 
most common present the appearance of deeply stained granules in 
faintly stained bacilli. 

Fig. 32. 



«. — • «*» 

7- v* 

CO 

Bacillus of diphtheria. (Abbott.) 

a. Its morphology when cultivated on glycerin agar-agar. b. Its morphology as seen in 

cultures on Loffler's blood-serum. 

Streptococci are also seen, as a rule, and it may be said that the 
gravity of a case is directly proportionate to the number of strepto- 
cocci present. 

It is important to note that diphtheria bacilli may still be found 
in the throat for weeks after all clinical symptoms have disappeared. 
Patients should hence be isolated until a bacteriological examination 
has demonstrated the absence of the organism. 

Literature. — S. Flexner, "The Bacteriology and Pathology of Diphtheria," Bull. 
Johns Hopkins Hosp., 1895, p. 39. W. H. Welch, Am. Jour. Med. Sci., 1894. Heub- 
ner, Schmidt's Jahrbiicher d. gesammten Med., 1892, vol. ccxxxvi. p. 270. Klebs, 
Arch. f. exper. Path., 1875, vol. iv. p. 207. Loftier, Centralbl. f. Bakt. u. Parasit., 
1887, vol. ii., p. 105, and 1890, vol. vii., p. 528. C. Friinkel, "Die Unterscheidung d. 
echten u. d. falschen Diphtheriebacillen," Berlin, klin. Woch., 1897, p. 1087. 




CHAPTER III. 
THE GASTRIC JUICE AND GASTRIC CONTEXTS. 

THE SECRETION OF GASTRIC JUICE. 

The gastric juice is the result of the glandular activity of the 
stomach, and is the only secretion of the digestive tract which pre- 
sents an acid reaction. 

As is well known, the mucous membrane of the stomach is cov- 
ered throughout its entire extent by a single layer of cylindrical 
epithelium, which dips down in places to line the orifices and larger 
ducts of the numerous tubular glands with which it is beset. Of 
these, two kinds are described, viz., the fundus and pyloric glands, 
so named from the location in which they are principally found. 
In the secretory portion of a fundus gland two sets of cells can be 
distinguished. The one kind is small, granular, and polyhedral or 
columnar, bordering upon the narrow lumen of the tube ; these are 
termed the chief or principal cells (Heidenhain ), but are also known 
as the central or adelomorphous cells. They stain with anilin dyes 
to only a slight extent. The others, known as parietal, adelomor- 
phous, or oxyntic cells, are variously situated between the adelomor- 
phous cells and the membrana propria ; they are most numerous 
in the necks of the glands. They are larger than the chief cells, oval 
or angular and finely granular in structure : they possess a strong 
affinity for the anilin dyes. The pyloric glands, which are found 
only in the region of the pylorus, on the other hand, are character- 
ized by the greater length of their ducts, which are also lined by 
the cylindrical epithelium of the mucous membrane proper. The 
secretory portion of these glands is represented by a single layer of 
short and finely granular, columnar cells, which closely resemble the 
chief cells of the fundus glands. In addition to these, a few isolated 
cells, the cells of Nussbaum, are found, which in structure and in 
their behavior to anilin dyes resemble the parietal cells. 

Upon chemical examination the gastric juice is found to consist 
essentially of water, free hydrochloric acid, pepsin, rennet (a milk- 
curdling ferment ). mucus, and certain mineral salts. 

Of these constituents, the hydrochloric acid is secreted by the 
parietal cells, pepsin and the milk-curdling ferment by the chief 
cells of the fundus and the pyloric glands, while the mucus is the 
product of the cylindrical goblet-cells lining the stomach and the 

14- 



TEST-MEALS. 149 

wider portions of its glandular ducts. It should be borne in mind, 
however, that the ferments mentioned do not exist in the cells as 
Mich, but as zymogens, which are transformed into the ferments 
through the activity of the free hydrocnloric acid. According to 
modern investigations, moreover, the zymogens only are secreted by 
the cells. 

Until recently it was supposed that the gastric juice is secreted only 
upon appropriate stimulation of the nervous mechanism of the stom- 
ach, either directly or indirectly, and that the stomach in its quiescent 
state — /. e.j when not digesting — is empty. The researches of 
Schreiber and Martins, however, have rendered the correctness of 
this view doubtful, as they were able to obtain quantities of gas- 
tric juice, varying from 1 to 60 c.c, from the non-digesting stom- 
ach of every normal person examined. I have likewise never failed 
to obtain a few cubic centimeters under the same conditions. 



TEST-MEALS. 

Although the secretion of gastric juice takes place continuously, 
the amount that can usually be obtained from the non-digesting 
organ is not sufficient for analytical purposes. It is, therefore, nec- 
essary to stimulate the glandular apparatus of the stomach to in- 
creased activity. This may be accomplished with thermic, chemical, 
electrical, and digestive stimuli, of which the last named are the 
most convenient and the most effective, furnishing an idea not only 
of the secretory, but also of the motor and resorptive activity of the 
organ. The analytical results will, however, depend to a large ex- 
tent upon the character of the food ingested, starches and fats exert- 
ing but a slight stimulating effect, while proteids cause a copious 
secretion of gastric juice. The ingestion of fluids at the same time 
will likewise influence the results obtained, owing to dilution of 
the gastric juice. The time of the height of digestion, moreover, 
varies with the kind and quantity of food taken. In order to obtain 
uniform results it is necessary, therefore, to withdraw the gastric 
contents at a certain period after the ingestion of a meal of known 
composition and bulk. 

Numerous test-meals have been proposed. The following are the 
most important : 

The Test-breakfast of Ewald and Boas. 

This consists of from 35 to 70 grammes of wheat-bread and of 
300 to 400 c.c. of water or weak tea, without sugar. It is best to 
give this meal to the patient early in the morning, when the stomach 
is empty — i. c, as a breakfast. The gastric contents are obtained 
one hour later. 



150 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

The Test-dinner of Riegel. 

This consists of a plate of soup (400 c.c), a beefsteak (200 
grammes), a slice or two of wheat-bread (50 grammes), and a glass- 
ful of water (200 c.c). The contents of the stomach are obtained 
after four hours. The disadvantage of this method lies in the fact 
that the lumen of the stomach-tube is frequently occluded by large 
pieces of undigested meat, a source of annoyance which may be 
guarded against, however, by using finely chopped meat. 

The Double Test-meal of Salzer. 

For breakfast the patient receives 30 grammes of lean, cold roast, 
hashed or cut into strips sufficiently small not to obstruct the 
stomach-tube ; 250 c.c. of milk ; 60 grammes of rice ; and one soft- 
boiled egg. Exactly four hours later the second meal is taken, con- 
sisting of 35 to 70 grammes of stale wheat-bread and 300 to 400 
c.c. of water. The gastric contents are withdrawn one hour later. 
In this manner the gastric juice is not only obtained at the height of 
digestion, but an idea may at the same time be formed of the motor 
power of the stomach. Under normal conditions the organ should 
contain no remnants of the first meal at the time of examination. 

The Test-breakfast of Boas. 

This consists of a plateful of oatmeal-soup, prepared by boiling 
down to 500 c.c. one liter of water to which one tablespoonful of 
rolled oats has been added. A little salt may be used if desired, 
but nothing more. The contents of the stomach are obtained one 
hour later. This test-meal was devised by Boas in order to guard 
against the introduction from without of lactic acid, which is present 
in all kinds of bread. The meal is employed in cases of suspected 
cancer of the stomach in which a quantitative estimation of lactic 
acid is to be made, the stomach being washed out completely the 
night before. 

Still other test-meals have been suggested, but they possess no 
material advantage over those described. 

THE STOMACH-TUBE. 

The stomach-tubes in general use are essentially large Nelaton 
catheters. They should measure at least from 72 to 75 cm. in 
length, and be provided with three fenestra, of which one is placed 
at the end of the tube and two laterally, as near the end as possible. 
For the purpose of washing out the stomach the tube is connected 
with a glass funnel by means of ordinary rubber tubing, which can 
be detached from the stomach-tube proper. There is no advantage 
in rubber funnels or in having a continuous tube. 



THE STOMACH-TUBE. 



151 



It is important that the tubes should be thoroughly cleansed in 
hot water as soon after use as possible. The advice of Boas, more- 
over, to have special, marked tubes for tubercular, syphilitic, and 
carcinomatous patients, should be borne in mind. Patients in whom 
lavage is to be practised for any length of time should provide their 
own instruments. 



Contraindications to the Use of the Tube. 

Of direct contraindications to the use of the tube, there should 
be mentioned the existence of the various forms of valvular disease 
when in a state of imperfect compensation, angina pectoris, arterio- 
sclerosis of high degree, aneurism of the large arteries, recent hem- 
orrhages from whatever cause, marked emphysema with intense 
bronchitis, acute febrile diseases, etc. 



Fig. 33. 



Introduction of the Tube. 



The technique of the introduction of the 
tube should be as simple as possible ; the 
exhibition of complicated bottle arrange- 
ments for the purpose of obtaining the 
gastric juice only adds to the excitement of 
a nervous patient, and should be avoided. 
The patient's clothing and floor of the room 
should be protected from being soiled by 
material that mav be vomited along the 
sides of the tube, the dribbling of saliva, 
etc. For this purpose, Tiirck's rubber bib 
with pouch may be advantageously employed. 
" It is so arranged as to form a pouch in 
front, to catch the saliva or stomach contents 
that may be thrown off from the mouth or 
stomach. A detachable tube passes from 
the bottom of the pouch and is conducted 
into a basin or any suitable vessel." 1 

Cocainization of the pharynx is not nec- 
essary, but may be resorted to in hyperaes- 
thetic individuals, a 10 per cent, solution 
being employed. 

The tube, held like a pen, is passed to the posterior wall of the 
pharynx, the patient bending his head forward, cud not backward, 
as is usually advised. The patient is then told to swallow, but this 
is not necessary. The tube is pushed on until resistance is felt 
when it meets with the floor of the stomach. The procedure does 
not occupy ten seconds. At the least sign of cyanosis or of marked 

1 Manufactured by G. Tiemaun & Co., New York. 




Boas' bulbed tube. 



152 THE GASTRIC JUICE A XL GASTRIC COS TESTS. 

pallor the tube should be withdrawn at once, and the patient ob- 
served for a day or two before a second attempt is made. 

If the gastric juice does not flow at once, the patient is instructed 
to bear down with his abdominal muscles, and. if this is insufficient, 
to cough a little. Repeated attempts of this kind will usually bring 
at the desired result, unless the tube has not been introduced far 
enough or too far : in the latter case it will double upon itself. - 
that its end rises above the level of the liquid. Pressing upon 
the abdomen with the hands is of no effect (Method of Expression). 

Aspiration must at times be employed. For this purpose, Boas 1 
bulbed tube (Fig. 33) is convenient. The manner in which it is 
used is the following : the proximal end of the tube, after having 
d introduced into the stomach, is compressed and the bulb 
squeezed, when the distal end is clamped and the bulb allowed to 
expand. AVhen this is repeated several times a partial vacuum is 

Fig. £4. 




Arrangement of bottle for aspiration of the gastric contents. 

produced in the tube, which usually causes a flow of gastric juice. 
In the absence of such an instrument the stomach-tube mav be con- 
nected with a b<»ttle. in which a partial vacuum has been established 
by aspiration a . Unless the patient is accustomed to the 

uction of the tube, b'-wever. these more complicated proced- 
ures should be avoided as much as possible (Method of Aspiration). 
I have found that in cases in which gastric juice cannot be ob- 
tained by expression the flow may often be started by suction with 
the mouth, and I regard this method as preferable to the one just 
described. With due precautions, viz.. holding the tube between the 
fingers near the mouth of the patient, so as to be informed at once, 
by the - s ■' touch, when the stomach contents have reached this 
point, unpleasant results will be obviated. If only a very small 
amount of gastric juice is present in the stomach — i. c. when a deli- 



GENERAL CHARACTERISTICS OF THE GASTRIC JUICE. 153 

nite flow cannot be established — it is best to suck lightly with the 
mouth, to compress the tube firmly, to remove it as rapidly as pos- 
sible, and empty it into a little dish. A few drops, sufficient to test 
for free hydrochloric acid, can thus always he obtained, even from 
the non-digesting organ. 

EKnhom's bucket-method is of little value, as the amount of gastric 
juice which can thus be obtained is insufficient tor analytical pur- 
poses. It may be employed, however, in patients who are particu- 
larly nervous, and who object to the use of the tube, and possibly 
also when its use is contraindicated. The test for hydrochloric 
acid can be made, but the information thereby obtained is in itself of 
comparatively little value. 

In order to wash out the stomach, the funnel-tube is attached, the 
funnel filial with lukewarm water or any desired medicated solution, 
elevated above the head of the patient, and the water allowed to 
flow. From 500 to 1000 c.c. may be introduced at one time. By 
suddenly depressing and inverting the funnel over a suitable vessel 
before all water has left the funnel a siphon arrangement is estab- 
lished and the stomach emptied. It is well to measure the return- 
ing water as well as the amount introduced. Should the flow 
diminish or cease before all the water has been removed, the end 
of the tube probably stands above the level of the liquid, and the 
flow can be started again by pushing the tube on further or by 
withdrawing it a little, as the case may be. 

Wash! ng out the stomach soon after the ingestion of a full meal is 
always very tedious and annoying, if not an impossible procedure, 
as the fenestra readily become obstructed. Should this occur, the 
funnel, filled with water, is elevated as high as possible, with a view 
to overcome the obstruction by hydrostatic pressure; or, if this 
proves insufficient, the funnel-tube is detached and the obstruction 
dislodged by means of air, for which purpose a Politzer bag or the 
bulb of a Boas tube is very convenient. 

GENERAL CHARACTERISTICS OF THE GASTRIC JUICE. 

Pure gastric juice is an almost clear, faintly yellowish fluid, of a 
sour taste and a peculiar, characteristic odor. Its specific gravity 
varies between 1.002 and 1.003, corresponding to the presence of 
but 0.5 per cent, of solids. Its reaction, owing to the presence of 
hydrochloric acid, is acid. 

Amount. 

Very little is known of the total quantity of gastric juice that is 
secreted in the twenty-four hours. The figure given by Beaumont, 1 

viz., 180 grammes pro die, based upon observations made upon the 

often-quoted Canadian hunter, Alexis St. Martin, i< undoubtedly too 

1 Beaumont, Experiments and Observations on the Gastric Juice, Boston, 1834. 



154 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

low. The amount given by Bidder and Schmidt/ viz., that corre- 
sponding to about one-tenth of the body-weight, is probably more 
nearly correct. 2 It may be stated a priori, however, that the quantity 
secreted varies within wide limits, being influenced by numerous 
factors, and notably by the degree of the appetite and the amount and 
character of the food taken, especially that of the proteids. The 
age and sex of the individual, the time of day (notably in its relation 
to the ingestion of food), the emotions, etc., all influence the glandular 
activity of the stomach. 

From the non-digesting organ, as has been pointed out, from 1 to 
60 c.c. of gastric juice may be obtained at one time. The amount 
which can be procured during the process of digestion, on the other 
hand, varies with the amount of liquid ingested, the time of expres- 
sion, the size and motor power of the stomach, and the degree of 
transudation ; the process of resorption probably does not play any 
part, as it has been ascertained that very little water, if any, is 
absorbed in the stomach. 

According to Boas, from 20 to 50 c.c. of filtrate can normally be ob- 
tained exactly one hour after the ingestion of Ewald's test-breakfast. 3 

Abnormally large quantities of gastric juice are practically found 
only in cases of so-called hypersecretion, the " Magensaftfluss " of 
the Germans, which may occur periodically or continuously. For- 
merly the presence of appreciable quantities of gastric juice in the 
non-digesting organ was regarded as conclusive evidence of the 
existence of this condition, but in the light of Schreiber's researches 
this position can no longer be maintained. The diagnosis should, 
hence, only be made when in conjunction with the clinical symptoms 
of hypersecretion from 100 to 1000 c.c. of pure gastric juice can be 
obtained from the non-digesting organ. To this end, the stomach 
should be emptied completely by the tube, before retiring, and an 
examination made on the following morning, no food or liquids 
being allowed in the meantime. 

In various pathological conditions abnormally large quantities of 
liquid may be obtained, which cannot be regarded as gastric juice, how- 
ever. Attention will be drawn to these conditions at another place. 

CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 

Chemical Composition of the Gastric Juice. 

As has been briefly shown above, gastric juice consists of water, free 
hydrochloric acid, certain ferments and their zymogens, and mineral 
salts. Analyses giving the exact chemical composition of pure, un- 
contaminated gastric juice in man are wanting, owing to the difficulty 

1 Bidder u Schmidt, Verdauungssafte u. d. Stoffwechsel. 1S52. 

2 Griinewald's figure— t. e., 1580 grammes— I likewise regard as too low. According 
to my experience, the daily secretion appears to vary between 2000 and 3000 c.c. 

3 Biegel, Die Erkranknngen des Magens, Part I. p. 88. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 155 

of excluding the saliva. In patients the subjects of gastric fistula 
analytical studies have, however, been made, and from the table 
below, taken from Schmidt, an idea may be formed of the various 
amounts of solid constituents contained in 1000 parts of gastric 
juice, uncontaminated by food or the products of digestion, but not 
free from saliva : 

Water 994.40 

Solids 5.60 

Organic material 3.19 

Sodium chloride 1.46 

Calcium chloride 0.06 

Potassium chloride 0.55 

Ammonium chloride . . 

Hydrochloric acid 0.20 

Calcium phosphate ^ 

Magnesium phosphate > 0.12 

Iron phosphate j 

The Acidity of the Gastric Juice is Referable to the 
Presence of Free Hydrochloric Acid. 

It has been conclusively demonstrated by Schmidt that the acidity 
of the gastric juice is due to the presence of free hydrochloric acid. 



P.M. Fig. 35. 








5 X 


ot i 


— ° 








° 




i T : 




«--"" "4"» 


15 " * - ■ v 


k^> 


! >*n 


> ' 


-.3--J- + 


1°5 /\ 




/ 


J it 




10 / 






t 


t 






£ .. ^ 


-y__,z fc _3; = __: === ^__ __:h±__± 


- / /• 




• / /] s 


/ ' ' 


/ ' 






/' 


Y 


' 


II III 1 II II 1 II II 1 1 i 



10 20 30 40 50 60 10 80 90 100 

Illustrating the curve of acidity after Ewald's test-breakfast. (Rosenheim.) 

Hydrochloric acid. Lactic acid, x Beginning of the stage of free hydrochloric acid. 

P. M. Pro mille. The numbers upon the abscissa indicate the minutes. 

After accurately determining the amount of chlorine and all basic 
substances present, it was found that after the latter had been satu- 



156 



THE GASTRIC JUICE AXD GASTRIC CONTENTS. 



rated a quantity of hydrochloric acid still remained, which in the 
dog varied between 0.25 and 0.42 per cent,, with an average of 0.33 
per cent. The amount of free acid was also determined by titration 
and the same results reached as by gravimetric analysis. 

\Yhile the acidity of pure gastric juice — i. <?., gastric juice not 
contaminated with saliva or food in various stages of digestion — 
is thus solely due to the presence of free hydrochloric acid, other 
factors enter into consideration in the examination of the gastric 
contents during the process of digestion. Acid salts and varying 
amounts of lactic acid derived from the carbohydrates ingested are 

Fig. 36. 















1 1 1 




: 


T» -mr 


















Jr.Jn..- 




■ 






























































































































o - 


























































■ 






















i 
































































































l 1 












1 




— --*■ \! 1 
































x I^S^^ 
















Ml 






J>s 


li 




p>i 
















L 


' 






















j>T] 






\ 
























>J 










y 


















X 












>1 
























' — J 


































































































Ml] 


1 










/ '~ 


~ 













' 




1 n 




/ 1 








~*~ 












/ 


' 


















f 




. 






























-JJ 
















T i +. 




n - 


I / 










T . 




0.O 










■ 






1 / 
















J+ 




















tr 












■ 








' 






1 i i 1 













30 60 90 120 150 ISO 210 240 270 300 



Illustrating the curve of acidity after Eiegel's test-meal. (Rosenheim.) 
-Hydrochloric acid. Lactic acid. X Beginning of the stage of free hydrochloric acid. 



then also found. At the beginning of digestion the acidity, accord- 
ing to Ewald, is due to a certain extent to the presence of lactic 
acid. 1 Hydrochloric acid, it is true, is present at the same time, 
but is held in combination by albuminous material. Later on, 
when the albuminous affinities have become saturated, it appears as 
such, with the result that the formation of lactic acid progressively 
diminishes, owing to the inhibitory action on the part of the hydro- 
chloric acid upon the lactic-acid-producing organisms. 2 

1 Ewald. Klin. d. Verdaunngskrankheiten, 1890, vol. i. Ewald u. Boas. Beitr. z. 
Physiol, u. Path. d. Verdauung. Virchow's Archiv. 1885, vol. ci. p. 355, and 1886, 
vol. civ. p. 271. See Lactic Acid, p. 183. 

- H. Straus- u. F. Bialocour, " Ueber d. Abbangigkeit d. Milchsauregahrung v. 
HC1 — Gehalt d. Magensaftes," Zeit. f. klin. Med., vol. xxviii. p. 567. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 157 

The varying degrees of acidity at different periods of digestion, 
after such test-meals as those of Ewald and Riegel, and t lie amount of 
the two acids present, may be seen from the accompanying diagrams 
(Figs. 35 and 36). 

Under pathological conditions the amount of free hydrochloric 
acid, as will be shown, may undergo great variations, diminishing on 
the one hand to zero, and increasing on the other to 0.5 percent., or 
even more. At the same time the amount of lactic acid, which 
normally is present in very small amounts, and is absent altogether 
at the height of digestion, may greatly increase. Fatty acids, more- 
over, which are normally not present in the gastric juice, may then 
also be observed. It is thus seen that the total acidity of the gas- 
tric juice, especially in disease, cannot be regarded as indicating the 
amount of one single acid, unless the absence of other acids and 
acid salts is insured. 



Method of determining the Total Acidity of the Gastric 

Contents. 

To this end, a known quantity of gastric juice is titrated with a 
one-tenth normal solution of sodium hydrate, using phenolphthalein 
as an indicator, when the number of cubic centimeters of the one- 
tenth normal solution employed, multiplied by the equivalent of 1 c.c. 
of this solution in terms of hydrochloric acid, will indicate the 
amount of acid present, from which the percentage-acidity is readily 
calculated. 

A normal solution of sodium hydrate is one containing the equiva- 
lent of its molecular weight in grammes — i. e., 40 grammes — in 
1000 c.c. of distilled water; a decinormal solution will, therefore, 
contain 4 grammes in the same volume of water. This quantity is 
dissolved in less than 1000 c.c. and the solution brought to the 
proper strength by titrating it with a solution of oxalic acid of 
known strength. 

From the equation 

2XaOH + C 2 H 2 4 = C 2 Na,0 4 + 2H 2 0, 

it is seen that two molecules of NaOH (molecular weight 40) com- 
bine with one molecule of C 2 H 2 4 + 2H 2 (molecular weight 126), 
or 4 parts by weight of the former with 6.3 of the latter. One-tenth 
gramme of oxalic acid would hence require 15.873 c.c. of the one- 
tenth normal solution of NaOH for its neutralization, as is apparent 
from the equation 

100 
6.3 : 1000 : : 0.1 : x ; 6.3z = 100, and x = ^ = 15.673. 



158 THE GASTRIC JUICE AND GASTRIC COSTENTS. 

One-tenth gramme of pure crystallized oxalic acid is dissolved in 
distilled water, and the solution titrated Avith the one-tenth normal 
solution of sodium hydrate, which is to be corrected, using two or 
three drops of a 1 per cent, alcoholic solution of phenolphthalein as 
an indicator, until the rose color of the solution has entirely disap- 
peared ; 15.9 c.c. should bring about this result. As the ]SaOH 
solution, however, has been purposely made too strong, less will be 
required. The amount of water that must then be added in order to 
bring the solution to its proper strength is determined by the formula 

O — - — , in which C represents the number of cubic centimeters of 
n 

water which must be added to the remaining solution, X the total 
number of cubic centimeters remaining after one titration, n the 
number of cubic centimeters consumed in one titration, and d the 
difference between the number of cubic centimeters theoretically 
required and that actually used in one titration. The solution hav- 
ing thus been properly diluted, the correctness of its strength is 
again tested and a further correction made, if necessary, until abso- 
lute accuracy has been attained. 

1000 c.c. of the one-tenth normal solution containing 4 grammes 
of XaOH are equivalent to 3.65 grammes of HC1, as is seen from 
the equation 

KaOH -f HC1 = XaCl - E^O 

40 36.5 

1000 c.c. of the T X o normal solution represent 3.65 grammes of HC1 

100 " " " " " " 0.365 gramme " " 

10 " " " " " " 0.0365 " " " 

1 " " " " " represents 0.00365 " " " 

Application to the Gastric Juice. — Five or 10 c.c. of the filtered gas- 
tric juice are titrated with the one-tenth normal solution of sodium 
hydrate, using two or three drops of a 1 per cent, alcoholic solution 
of phenolphthalein, as an indicator, until the rose color which appears 
after the addition of every drop of the sodium hydrate solution no 
longer disappears on stirring or becomes deeper after the addition of 
a further drop. The number of cubic centimeters of the one-tenth 
normal solution employed multiplied by 0.00365 will then indicate 
the acidity of the 5 or 10 c.c. of gastric juice in terms of HC1, from 
which the percentage-acidity is calculated. 

Example. — Ten c.c. of gastric juice required the addition of 6.5 
c.c. of the one-tenth normal solution ; 6.5 X 0.00365 (/. e., 0.0237) 
would hence indicate the acidity of the 10 c.c. of gastric juice in 
terms of HOI, and 0.0237 X 10 = 0.237, the percentage-acidity. 

As these figures express the amount of HC1 in pure gastric juice 
obtained only from normal individuals, it has been found more con- 
venient for clinical purposes merely to indicate the degree of acidity 
bv the number of cubic centimeters of the one-tenth normal solution 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 159 



employed. In the above example, in which 6.5 c.c. were used, the 
percentage acidity would thus be indicated by the figure <>o — i. e. f 

tlic Dumber of cubic centimeters of the one-tenth solution necessary 
to neutralize 100 c.c. of gastric juice. 

Under normal conditions figures varying from 40 to 60 are usually 
obtained one hour alter the ingestion of Ewald's test-breakfast, 
while in pathological conditions greater variations are observed. 
In acute and chronic inflammatory conditions of the stomach, 
as well as in some of the neuroses, the acidity of the gastric contents 
is below normal. Higher figures are met with in cases of ulcer, in 
some cases of dilatation, and are especially frequent in some of the 
neuroses, in which a degree of acidity corresponding to 90 or even 
more is not infrequently observed. Increased acidity, usually asso- 
ciated with hypersecretion of gastric juice, is met with in the so- 
called hypersecretio aeida et continua of Reiclimann. 1 

It has been pointed out that the reaction of normal gastric juice 
is always acid, owing to the presence of free hydrochloric acid, and 
the same may be said to hold good for the gastric contents in general, 
obtained from a normal individual. Pathologically an acid reaction 
is also the rule, as in those cases in which hydrochloric acid is absent 
fatty acids and lactic acid usually make their appearance. It is, 
therefore, not surprising that an alkaline, neutral, or amphoteric 
reaction is but rarely, or at least not commonly, observed in the 
gastric contents artificially obtained, and practically seen only in 
the so-called mucous form of chronic gastritis, or in those rare cases 
of anadeny, in which a complete destruction of the gastric glands 
has taken place. In vomited material, on the other hand, such 
observations are common, owing to the presence of large amounts 
of saliva. The vomited material in cases of so-called vomiim 
rnatutinus, which is usually referable to a chronic catarrhal condition 
of the pharynx, generally presents an alkaline reaction, owing to 
the fact that the fluid brought up is largely unchanged saliva. 

Source of the Hydrochloric Acid. 

That the hydrochloric acid is not directly derived from the chlo- 
rides ingested is shown by the fact that it is secreted by starving 
animals. The same point is also proved by the observations of 
Schreiber, which go to show that the secretion of the acid is con- 
tinuous, not to mention the well-known fact that even after the 
ingestion of material free from chlorine an acid gastric juice is 
secreted. It is apparent, then, that the chlorides of the blood must 
furnish the necessary chlorine, and as the pyloric glands, which con- 

1 Reichmann. Berlin, klin. Woch., 18S2, vol. xix. p. 606; 1884, vol. xxi. p. 768; 
1887, vol. xxiv. p. 12. 



160 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

tain no parietal cells, furnish an alkaline, and the fundus glands, 
which do contain parietal cells, an acid secretion, it is thought that 
these parietal cells are in some manner concerned in the production 
of the hydrochloric acid. The exact manner in which this takes 
place has not been definitely ascertained, but it is not improbable 
that the acid results from a " MasseneinwirkuDg " on the part 
of the carbonic acid, which is present in large quantities in the 
blood as such, upon the sodium chloride, and that owing to a specific 
action on the part of the parietal cells the hydrochloric acid is 
secreted into the ducts of the glands of the stomach, while the 
sodium carbonate which is formed at the same time returns to the 
blood. 

Two factors are thus necessary in order that a normal amount of 
hydrochloric acid should be secreted — i. e., a normal condition of 
the blood and a normal condition of the cells. Whenever the 
integrity of either of these factors becomes impaired, it is clear 
that an abnormal secretion of hydrochloric acid or none at all will 
result. The nervous system, furthermore, must be taken into con- 
sideration as a third factor, as normal innervation is the sine, qua 
non for the normal activity of any organ. The secretion of the 
acid is impaired whenever the nutrition of the cells of the stomach 
suffers, whether this be the result of inflammatory lesions, new 
growths, or hypersemic conditions of the stomach, the effect of 
renal, hepatic, or pulmonary diseases, etc., or in consequence of 
central or peripheral nerve influences. 

In the secondary dyspepsias, then, the result of renal, hepatic, 
cardiac, or hsemic diseases, etc., an examination of the gastric juice 
for free hydrochloric acid is of comparatively little value from a 
diagnostic standpoint, although it may suggest valuable points for 
the dietetic treatment of such patients. 

Significance of Free Hydrochloric Acid. 

Formerly it was believed that the principal function of the stomach 
was a digestive one, and that in the stomach, owing to the action of 
hydrochloric acid and pepsin, albumins were to a large extent 
transformed into peptones and albumoses. As pepsin is active only 
in the presence of a free acid, it was thought, moreover, that the 
power of the hydrochloric acid to render pepsin physiologically 
active constituted its entire field of usefulness. 

It had been noted over one hundred years ago, however, by the 
Abbe Spallanzani, that pieces of meat immersed in gastric juice 
resist the process of putrefaction for days. When it was shown, 
later on, that the free mineral acids are powerful antiseptics, and 
that the stomach secretes an amount of free hydrochloric acid 
sufficient to prevent the development of most of the putrefactive 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 161 

organisms, the time had come to doubt the correctness of the view 
previously held. 

Numerous experiments have been made in order to test the anti- 
septic and germicidal power of the gastric juice. Among the more 
important results achieved the following may be mentioned : the 
comma bacillus of cholera Asiatica is destroyed by normal acid 
gastric juice, while infection results when this has previously been 
neutralized. The same holds good for numerous other pathogenic 
organisms which are of special interest to the clinician. Among 
these may be mentioned the various species of streptococcus, Staphylo- 
coccus pyogenes aureus, the bacillus of anthrax, etc. Unfortunately, 
however, not all species of pathogenic organisms are destroyed by the 
acid of the gastric juice, and the spores, moreover, of some of those 
that are destroyed are possessed of a considerable degree of resist- 
ance. This is especially true of the tubercle bacillus and in many 
cases of ths spores of the anthrax bacillus. 

Those bacteria also which cause lactic acid and butyric acid fer- 
mentation resist the antifermentative power of the gastric juice to a 
certain extent, as may be concluded from the fact that they are 
always present in the intestines. At the beginning of the process of 
gastric digestion, when the hvdrochloric acid secreted is immediatelv 
taken up by the albuminous bodies present, traces of lactic acid can 
usually be demonstrated in the gastric contents if carbohydrates 
have been ingested. Later on, when free hydrochloric acid appears, 
lactic acid fermentation ceases. This observation is in accord with 
the fact that the action of the lactic acid producers is prevented by 
the presence of 0.7 pro mille of free hvdrochloric acid. 

From what has been said it may be argued that as the principal 
function of the stomach consists in the furnishing of an antiseptic 
and germicidal fluid, under suitable conditions life could go on in 
the absence of the stomach. That this is possible has been demon- 
strated by Czerny, who succeeded, in removing almost the entire 
organ from a dog. Five or six years later the same animal Avas 
killed in Ludwig's laboratory, and it was found at the autopsy that 
"near the cardia a small portion of the stomach had remained, 
surrounding a globular cavity filled with food." This dog then had 
lived for almost six years practically without a stomach, had gained 
in weight, and was to all intents and purposes as healthy an animal 
as one provided with an entire organ. In the human being similar 
observations have been made on subjects of carcinoma of the stomach. 
Tt is thus very probable that the stomach, so far as the process of 
digestion is concerned, is not necessary for the maintenance of life. 

Literature. — Spallanzani. Experiences sur la digestion de l'homme et de difler- 
entes especes d'animaux, Geneve, 17-1. Bunge, Lehrbuch d. physiol. Cbem., 1889, 
p. 11. Mester, " Ueber Magensaft u. Darmfaulniss," Zeit. f. klin. Med., vol. xxiv. p. 
411. Schmitz, " Zur Kenntniss d. Darmfaulniss." Zeit. f. physiol. Chem., vol. xvii. 
p. 401 ; " Die Beziehung d. Salzsiiure d. Magensaftes z. Darmfaulniss," Ibid., vol. xix. 

11 



162 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

p. 401. C. E. Simon, " On Indicanuria," Am. Jour. Med. Sci., 1895, vol. ex. p. 48. 
Czerny, Beitrage z. operativen Chirurgie, Stuttgart, 1878, p. 141. Ludwig u. Ogata, 
"Ueber d. Verdauung nach d. Ausschaltung d. Magens," Du Bois' Archiv, 1883, p. 89. 
J. Carvallo u. V. Pachon, " Untersuchungen iiber d. Verdauung bei einem Hunde 
ohne Magen," Arch, der Physiol., 1894, p. lOti. 

The Amount of Free Hydrochloric Acid. 

Pure gastric juice, according to Ewald, 1 Szabo, 2 and Boas, 3 con- 
tains from 2 to 3 pro mille of free hydrochloric acid. 

In the digesting organ such amounts are met with only at the 
height of digestion, and after all albuminous and basic affinities 
have been saturated. The time at which free hydrochloric acid can 
be demonstrated in the gastric contents after the ingestion of a meal 
will, hence, vary with the character of the food and its amount. 
When but little work is to be accomplished free hydrochloric acid 
is found much sooner than otherwise. After Ewald' s test-breakfast, 
for example, it appears after thirty -five minutes ; the point of maxi- 
mum acidity is reached after from fifty to sixty minutes, and corre- 
sponds to the presence of 1.7 pro mille. Following RiegeFs meal, on 
the other hand, the free acid appears after one hundred and thirty- 
five minutes, and reaches its highest point (corresponding to 2.7 pro 
mille) in from one hundred and eighty to two hundred and ten 
minutes (Figs. 35 and 36). 

Clinically it is necessary to distinguish between euchlorhydria, or 
the secretion of a normal amount of free hydrochloric acid (0.1 to 
0.2 per cent.), hypochlorhydria, or the secretion of a deficient 
amount (less than 0.1 per cent.), hyperchlorhydria, in which more 
than 0.2 per cent, is found, and, finally, anachlorhydria, in which 
no hydrochloric acid at all is secreted. 

Euchlorhydria. — Euchlorhydria, when associated with clinical 
symptoms pointing to gastric derangement, is most commonly ob- 
served in nervous dyspepsia. A chronic gastritis can always be 
excluded in the presence of a normal amount of the free acid, thus 
constituting a most important point in the differential diagnosis 
between the two conditions. A normal secretion of free hydro- 
chloric acid is, furthermore, observed in some cases of atony or 
hypatony of the muscular walls of the stomach. 

Hypochlorhydria. — Hypochlorhydria is associated with all those 
diseases in which the secretory elements have been more or less 
damaged, as in subacute and chronic gastritis, in some cases of ulcer 
of the stomach or the duodenum, in incipient carcinoma, dilatation, 
and atony. 

Anachlorhydria. — INTot many years ago it was thought that the 
absence of free hydrochloric acid from the gastric contents was 
pathognomonic of carcinoma of the stomach. This view was soon 
abandoned, however, as it was shown that cases of carcinoma occur 

1 Loc. fit, 2 D. Szabo, Zeit. f. physiol. Chem., 1877, vol. i. p. 155. 

3 Loc. cit. See also A. Schiile, Zeit. f. klin. Med., 1896, vols, xxviii. and xxix. 



CHEMICAL EXAMINATION OF THE GASTRIC JV ICE. L63 

in which hydrochloric acid is not only present, but present in ex- 
cessive amounts. This is true especially of those cases in which 
the malignant growth has started upon the base of an old nicer. 
It was, furthermore, shown that anachlorhydria exists in almost all 
cases of advanced chronic gastritis, and is a very common occur- 
rence in neurasthenic and hysterical individuals, constituting the 
so-called hysterical anacidity. 

Hyperchlorhydria. — The existence of hyperchlorhydria is gen- 
erally indicative of a gastric neurosis, and is thus frequently met 
with in its simplest form in certain neurasthenic individuals. Asso- 
ciated with a continuous hypersecretion of gastric juice it constitutes 
the neurosis that has been described under the term hypersecretio 
acida <i continua. Hyperchlorhydria is also of frequent occurrence 
in cases of gastric ulcer, and may even occur in carcinoma, notably 
in those cases iu which, as stated above, the new growth has started 
from an old ulcer. 

Test for Free Acids. 

Following a physical examination of the gastric contents, and, if 
acid, a determination of the total acidity, the next step will be to 
determine whether or not the acid reaction is referable to the pres- 
ence of a free acid, of combined acids, or of acid salts. 

The Congo-red Test. 1 — Congo-red is a carmin-colored powder, 
while its solutions are of a peach- or brownish-red color, which 
changes to azure blue upon the addition of a free acid, but remains 
unaffected in the presence of an acid salt. Congo-red may be em- 
ployed in solution or in the form of a test-paper. The latter, how- 
ever, is less delicate than the solution, and indicates only the pres- 
ence of 0.01 per cent, of hydrochloric acid, while a positive reaction 
can still be obtained with the aqueous solution in the presence of 
0.0009 per cent. The solution should be moderately dilute. The 
test-paper is prepared by soaking filter-paper, free from ash, in this 
solution, drying, and cutting it into suitable strips. In order to test 
for the presence of a free acid, it is only necessary to immerse a 
strip of the test-paper in the filtered gastric juice, or to add a drop 
or two of the solution to a small amount of the juice, when in the 
piv-ence of a free acid a blue color will develop, which varies from 
a sky-blue to a deep azure according to the amount present. A 
negative result will exclude at once the possibility of peptic activity, 
as pepsin acts only in solutions containing a free acid. If the 
result of the test is positive, the nature of the free acid must 
still be ascertained, and it is, therefore, necessary to test for free 
hydrochloric acid, or in its absence for lactic acid and certain fatty 
acids. 

1 Eiegel, Deutseh. med. Woch., 1886, No. 35 ; and Boas, Diagnostik u. Therapie d. 

Mamnkrankheiten. 



164 THE GASH.:. JUICE AMI ZASTBH COHTTENTSL 

Tests for Free Hydrochloric Acid. 

The various agents which maybe employed are given below, 
and are arranged according to their degree of delicacy, viz.: 

1. Dimethyl-amido-azo-benzol 0.02 pro mille 

2. Pliloroglucin-vanillin 0.05 " 

Resorcin 0.05 " 

4. TropsolinOO 0.30 

5. Mohrs reagent 1.00 u 

The Dimethyl-amido-azo-benzol Test.'- — This test is kn •-■-.. .\L« 
as roofer's test, and is destined to replace the older phlorogluein- 
vaDillin and resorcin tests in the clinical laboratory. The delicacy 
: the reagent is such that the natural yellow color of the indicator 
is .--hanged to a reddish tinge upon the addition of but one drop of 
a one-tenth normal solution of hydrochloric acid in 5 c.c. of dis- 
tilled water. Its superior delicacy, as compared with the phloro- 
glucin- vanillin and resorcin tests, is apparent from the fact that 5 
: " per cent. - lution of egg-albumin, to which six drops 

: one-tenth normal solution of hydrochloric acid have been added, 
still give a positive reaction with dimethyl-amido-azo-benzol, while 
the phloroglucin-vanillin and resorcin reactions are negative. 
( Organic acids yield a red color only when present in amounts 
exceeding " per cent.: but even then a negative reaction is ob- 
tained, if, as in the stomach, small quantities of albumins, pepfc 
or mucin are present at the same time. A positive reaction is then 
obtained only when the organic acids are present in amounts far 
exceeding 0.5 per cent. Lo - mbined hydrochloric acid and 

acid salts do not produce this change in color. 

For practical pui poses pei cent, alcoholic solution is em- 

ployed. One or two dr ps : this are added to a trace of the gastric 
contents, which need not be filtered : in the presence of free hydro- 
chloric acid a beautiful cherry-red color develops, which varies in 
intensity according to the amount of free aci - at A test-paper, 

prepared by soaking snips of filter-paper in the 0.5 ent. solu- 

tion and allowing them to diy. may also be employed. "With gastric 
juice containing no free hydrochloric acid, as with distilled water, a 
yellow color results, the fluid at the same time becoming cloudy and 
beautifully fluorescent. 

I have personally used Topfer'- test luring the last seven years. 
and prefer it to all otl 

The Phloroglucin-vanillin Test. 1 — The solution empl 
tains 2 gran bloroglucin and 1 gramme of vanillin, dissolved 

in 3 - -lute alcohol : a yellc Lor res ilts, which gradu- 

'• it. f. phvsiol. Chern.. vol. six. Hari. Arch. f. Verdauungsfcrank.. voLii. 
92 and 332. 

.zburg. OntTalbl. f. klin. Med.. 1887, vol. viii. No. 40. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 165 

ally turns a dark golden red, changing to brown when exposed to 
Light. The solution should therefore be kept in a dark-colored 
bottle. Lenhartz suggests the use of separate solutions of phloro- 

glncin and vanillin, one or two drops of each being employed in the 
test. Boas recommends a solution of the phloroglucin and vanillin, 
in the proportions indicated, in 100 grammes of 80 per cent, alcohol, 
and claims that the reagent is then still more sensitive and more 
stable. If a few drops of gastric juice, or even of the unfiltered 
gastric contents, containing 0.05 per cent, or more of free hydro- 
chloric acid, are treated with the same number of drops of the 
reagent, no change in color results, but upon the application of gentle 
heat — boiUng and rapid evaporation are to be avoided — a rose-tint or 
exceedingly fine rose-colored lines develop, which are characteristic 
of the presence of the free acid. 

For practical purposes it is best to carry on this slow evaporation 
on a thin porcelain butter-dish, the porcelain cover of a crucible, or 
in a small evaporating-dish of the same material. The color obtained 
in the presence of free hydrochloric acid is a rose color in every in- 
stance, and varies in intensity with the amount of acid present. A 
brown, brownish-yellow, or brownish-red color always indicates that 
excessive heat has been applied or that free hydrochloric acid is 
absent. 

Organic acids do not produce the reaction, nor is it interfered 
with by their presence, or that of albumins, peptones, or acid salts. 

A phloroglucin-vanillin test-paper, prepared by soaking strips of 
filter-paper, free from ash, in the solution and drying them, may 
also be employed. If a strip of this is moistened with a drop of 
gastric juice and gently heated in a porcelain dish, the rose color 
will develop in the presence of free hydrochloric acid, and does not 
disappear upon the addition of ether. 

The Resorcin Test. 1 — The solution consists of 5 grammes of 
resublimed resorcin and 3 grammes of cane-sugar, dissolved in 100 
grammes of 94 per cent, alcohol. It is equally as delicate as the 
phloroglucin-vanillin solution and has the advantage of greater 
stability. 

Five or six drops of gastric juice are treated with three to five 
drops of the reagent and slowly evaporated to dryness over a small 
flame, when a beautiful rose- or vermilion-red mirror will be obtained, 
which gradually fades on cooling. If the reagent is employed in 
the form of a test-paper, a violet color at first develops, which 
upon the application of heat turns brick red and does not disappear 
on treatment with ether. 

The presence of acid salts, organic acids, albumins, or peptones 
does not interfere with the reaction. 

1 Boas, Centralbl. f. klin. Med., 1888, vol. ix. No. 45. 



166 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

The Tropseolin Test. 1 — Tropseolin 00, when employed according 
to the method suggested by Boas, is a very reliable reagent, indi- 
cating the presence of 0.2 to 0.3 per cent, of free hydrochloric acid. 
Three or four drops of a saturated alcoholic solution of tropa?olin 00, 
which has a brownish-yellow color, are placed in a small porcelain 
dish or cover, and allowed to spread over the surface. A like amount 
of gastric juice is then added and likewise allowed to now over the 
surface of the dish : upon the application of gentle heat beautiful 
lilac or blue stripes appear, which are said to be absolutely character- 
istic of free hydrochloric acid. 

A tropseolin test-paper may also be prepared by soaking filter- 
paper, free from ash, in the alcoholic solution, and then drying and 
cutting it into strips. A few drops of gastric juice containing free 
hydrochloric acid produce a more or less pronounced brown color 
upon this paper, which turns lilac or blue upon the application of 
gentle heat. Organic acids, when present in large amounts, likewise 
produce a brown color, but this disappears on heating, and a lilac or 
blue color does not result. 

For ordinary purposes this test is sufficient, and recourse need only 
be had to the more delicate reagents when a negative or a doubtful 
result is obtained. 

Mohr's Test, as modified by Ewald. 2 — Two c.c. of a 10 per cent, 
solution of potassium sulphocyanide are treated with 0.5 c.c. of a 
neutral solution of ferric acetate, and diluted to 10 c.c. with distilled 
water, a ruby-red solution resulting. Of this, a few drops are placed 
in a porcelain dish, when a drop or two of the filtered gastric con- 
tents are allowed to come into contact with the reagent. In the 
presence of free hydrochloric acid a light- violet color develops at the 
point of contact between the two fluids, and turns a deep mahogany- 
brown upon mixing. 

The test is not interfered with by the presence of acid salts or 
peptones, but is not so sensitive as those already described. 

The Benzopurpurin Test. 3 — Benzopurpurin 6B has been highly 
recommended by v. Jaksch as a very sensitive test for hydrochloric 
acid. It is best used in the form of a test-paper, prepared by soak- 
ing strip- of filter-paper, free from mineral ash, in a concentrated 
watery solution of the reagent and allowing them to dry. 

In the presence of more than 0.4 gramme of hydrochloric acid 
in 100 c.c. of gastric juice the color of the test-paper immedi- 
ately turns a deep blaekisli-blue. Should a brownish-black color 
develop, this is likely due to the presence of organic acids, or. a mixt- 
ure of these and hydrochloric acid. If the color is caused by or- 

1 Ewald, Kliniiv d. "" --krank.. Berlin. 1S8S. vol. ii. ; and Boas. Deutsoh. mecL 

573 v.d. xiii. - 3SS 
1 Ewald n. B< - - Ax hiv. vol. ci. p. 32o : vol. civ. p. -271. 

3 v. Jaksch. Klinis<.he Diagnostik, 1396, p. 177. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. L67 

ganic acids only, it will disappear on washing the strip with a little 
neutral ether, the original color of the test-paper being thus restored ; 
but if due to a mixture of the two, the reaction is less marked, and 
does not disappear. According to Hellstrom, 1 0.39 milligramme of 
hydrochloric acid, dissolved in (I c.c. of water, can he recognized by 
the addition of only 5 milligrammes of benzopurpurin. 

Acid -alt-, peptones, and serum-albumin do not seriously inter- 
fere With the reaction. 

v. Jaksch claims that the benzopurpurin test-paper is more sensi- 
tive than the Congo-red paper. 

The Combined Hydrochloric Acid. 

It has been stated (see page 155) that the total acidity of the 
gastric juice can only be referred to hydrochloric acid when organic 
acids and acid salts are absent. But at the same time the free acid is 
titrated together with the loosely combined acid. The presence of free 
hydrochloric acid in normal amounts implies, of course, the existence 
of peptic activity, and indicates that all albuminous affinities have 
been saturated. In the absence of free hydrochloric acid, however, 
it i- important to know whether or not hydrochloric acid is secreted 
at all — i. c, whether peptic digestion is at a standstill or whether an 
amount is secreted that is sufficient to saturate only certain albu- 
minous affinities without appearing in the free state. In the treat- 
ment of the various forms of gastric disease, more especially those 
associated with an absence of free hydrochloric acid, accurate knowl- 
edge in this respect is important. If no hydrochloric acid at all is 
secreted, the stomach can only be regarded as a storehouse, as it 
w T<\ and proteids must be ordered in such a form that they may be 
subjected to the process of pancreatic digestion with as little delay 
as possible, the nutrition of the body being aided, if necessary, by 
a suitable administration of predigested food. If, on the other 
hand, an amount of hydrochloric acid is secreted which is sufficient 
to saturate the albuminous affinities of an ordinary meal, or at least 
of moderate amounts of proteids, the dietetic directions need not be 
80 stringent. While in the former case the absence of loosely com- 
bined hydrochloric acid usually indicates complete destruction of 
the glandular elements of the stomach — in other words, an irrepar- 
able condition — a fair prognosis may be given when the amount of 
acid secreted is sufficient for the saturation of the albuminous 
affinities of an ordinary meal. The following table 2 shows the 
amount of hydrochloric acid necessary to saturate the affinities of 
known quantities of various articles of food, the figures given having 
reference to 100 c.c. or 100 grammes : 

1 Cited by v. Jaksch. 

2 Taken, in part from personal observations, and in part from Ehrlicb, Dissert., 
Erlangen, 1893. 



168 THE GASTRIC JUICE AXD GASTBIC CONTENTS. 

Milk . 0.32-0.56 gramme of pure HCL 

Beef (boiledi 1.95-2.0 grammes " 

Murton (boiled) 1.9 

Teal (boiled 2.2 

Pork boiled! 1-5-1.6 

Sweetbread boiled i . J.9-0.95 gramme " 

Calves' brains (boilrdi 0.56-0.65 

Ham raw | 1.9 grammes " 

Ham boiled 1.3-l.S 

Flounder 1.41 

Liver sausage 0.8-O.9 gramme B " 

Cervelat sausage 1.1 grammes "' " 

Metftnust 1.0 gramme '" 

Bologna sausage 1.49 grammes " 

Blood sausage _: :_ me 

Potato mashed) 0.4S 

Eice milk' 1.22 grammes il " 

Corn ('.27 gramme " " 

Graham bread 0.3 " B B 

Pumpernickel 0.7 

Wheat bread 0.3-0.5 

Eye bread 0.3-0.5 

S^viss cheese 2.6-2.7 grammes " 

Frontage de Brie 1.3 " B " 

Edam cheese 1.4 

Roquefort cheese 2.1 u u " ; 

Beer (German I ......... . 0.07—0.15 gramme " ; 

Quantitative Estimation of the Hydrochloric Acid of the 
Gastric Juice. 

Tdpfer's Method. 1 — The free and combined hydrochloric acid is 
most conveniently estimated according to Tdpfer's method, which is 
both simple and sufficiently accurate for clinical purposes. 

Id this method the total acidity (a) of a given amount of gastric 
juice — /. c. the acidity referable to the presence of free hydrochloric 
acid, combined hydrochloric acid, acid salts, and any organic acids 
that may be present — is first determined (lactic acid and the fatty 
acids, if present, need not be removed), using phenolphthalein as an 
indicator. Tins is followed by a determination of the acidity refer- 
able to free acids and acid salts in the same amount of gastric juice 

. using alizarin (alizarin monosulphonate of sodium) as an indi- 
cator. As this does not react with loosely combined hydrochloric 
acid, the difference between a and b will indicate the amount 
of the latter. The free hydrochloric acid (c) finally is estimated with 
dimethyl-ainido-azo-benzol as an indicator, the difference between a 
and b — c giving the acidity referable to organic acids and acid salts. 

The solutions required are the following : 

1. A decinormal solution of sodium hydrate. 

2. A 1 per cent, alcoholic solution of phenolphthalein. 

3. A 1 per cent, aqueous solution of alizarin. 

4. A ent. alcoholic solution of dimethyl-amido-azo-benzol. 
Three separate portions of 5 or 10 c.c. of filtered gastric juice are 

measured int<.» three small beakers or porcelain dishes. To the 

1 Loc. cit. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 1G9 

first portion 1 or 2 drops <>t' phenolphthalein are added, when it 

IS titrated with the one-tenth normal solution of sodium hydrate. 
It is necessary, however, to titrate to the point of a deep red, and 
not to the rose line which first appears. It will he seen that upon 
the addition of the fust few drops of the one-tenth normal solution 
the red color, which first appears, disappears on stirring. Upon 
further titration a point is reached when this no longer occurs, and 
the color of the entire solution suddenly turns to a rose. This, 
however, is not the end-reaction that is desired. If the titration 
is continued, it will be observed that a dark-red cloud forms in the 
light rose-colored solution, which disappears on stirring; finally, a 
point is reached when an additional drop no longer intensities the color 
of the solution. This point is the end-reaction which must be reached. 
To the second portion 3 or 4 drops of the alizarin solution are 
added, when it also is titrated with the one-tenth normal solution of 
sodium hydrate until a pure violet color is obtained. As practice is 
required in order to determine this point with accuracy, Topfer 
advises to make previously the following simple tests : 

1. To 5 c.c. of distilled w^ater add 2 or 3 drops of alizarin solu- 
tion, when a yellow color will result. 

2. To 5 c.c. of a 1 per cent, solution of disodium phosphate add 
the same number of drops, when a red or slightly violet color will 
be obtained. 

3. Five c.c. of a 1 per cent, solution of sodium carbonate, treated 
with 2 or 3 drops of the alizarin solution, will strike a pure violet ; 
this is the color to which the titration must be carried. 

In the third portion of the gastric juice the free hydrochloric acid 
is titrated, after the addition of 3 or 4 drops of the dimethyl-am ido- 
azo-benzol, until the last trace of red — in the presence of free hydro- 
chloric acid — has disappeared. A yellow color resulting upon the 
addition of the indicator demonstrates the absence of the free acid, 
as has been shown on page 164. The results are then calculated as 
in the following example : 

Ten c.c. of gastric juice, using phenolphthalein as an indicator, 
required 10 c.c. of the one-tenth normal solution in order to bring 
about the end-reaction, while a like amount titrated in the same 
manner with alizarin required 7 c.c. in order to bring about the 
same result. The difference between 10 and 7 — i. e., 3 — would 
thus indicate the number of cubic centimeters necessary to neutralize 
the amount of hydrochloric acid in combination with albuminous 
material. As 1 c.c. of the one-tenth normal solution represents 
0.00365 gramme of hydrochloric acid, the amount of acid thus held 
will be equivalent to 0.00365 X 3 = 0.010f)o gramme of hydrochloric 
acid — i. e., 0.1095 per cent. 

In the estimation of the free hydrochloric acid, 2.3 c.c. of the one- 
tenth normal solution were required, using dimethyl-amido-azo-ben- 



170 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

zol as an indicator; this would correspond to 0.00365 X 3.2 — i. e., 
0.1168 per cent. The value of the total acidity in terms of hydro- 
chloric acid is 10 X 0.00365 = 0.0365 gramme for every 10 c.c. of 
gastric juice, or 0.365 per cent. By deducting the amount of the 
free and combined hydrochloric acid, viz., 0.1095 + 0.1168 = 0.2263, 
from this, it is found that the acidity of the gastric juice referable to 
organic acids and acid salts amounts to 0.1387 per cent., so that the 
results can be tabulated as follows : 

Free hydrochloric acid 0.1168 per cent. 

Combined hydrochloric acid 0.1095 " 

Organic acids and acid salts 0.1387 " 

Total acidity 0.3650 per cent. 

The Method of Martius and Liittke (modified). 1 — This method 
is equally exact, but requires a greater expenditure of time. It is 
based upon the fact that upon incineration of the gastric juice 
the free hydrochloric acid and that loosely combined with albu- 
minous material escape, while the chlorine in combination with 
inorganic bases remains in the mineral ash unless a very intense 
heat is applied for some time. By subtracting the amount of chlorine 
present in the latter form from the total amount, the quantity in 
combination with albuminous material and that occurring as free 
acid will be found. The total acidity of the gastric juice is then 
determined, and that referable to the presence of the free and com- 
bined hydrochloric acid subtracted, the difference giving the amount 
of organic acids present. By determining the acidity due to the pres- 
ence of free hydrochloric acid according to Topfer's method, and 
deducting the amount found from that referable to the presence of free 
and combined hydrochloric acid, the amount of the latter is obtained. 

Reagents required : 

1 . A solution of silver nitrate in nitric acid of such strength that 
1 c.c. shall represent 0.00365 gramme of hydrochloric acid. 

2. Liquor ferri sulphurati oxydati. 

3. A decinormal solution of ammonium sulphocyanide. 

4. A one-tenth normal solution of sodium hydrate. 

5. A 1 per cent, alcoholic solution of phenolphthalein. 

6. A 0.5 per cent, alcoholic solution of dimethyl-amido-azo-benzol. 
Preparation of the solutions : 

1. The silver nitrate solution. As a solution is required of such 
strength that 1 c.c. shall be equivalent to 0.00365 gramme of hydro- 
chloric acid, the amount of silver nitrate that must be dissolved in 
1000 c.c. of water is ascertained in the following manner: since 
169.66 (molecular weight) parts by weight of silver nitrate combine 
with 36.5 parts of hydrochloric acid (molecular weight), the amount 

1 F. Martius u. L. Liittke, Die Magensaure des Menschen, Stuttgart, 1892. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 171 

of silver nitrate required for each cubic centimeter is found from the 
equation 

169.66 : 36.5 : :x: 0.00365 ; 36.5 x 0.6192590; % — 0.0169. 

In 1 c.e. of the silver solution 0.0169 gramme of silver nitrate must 
thus be present, or 16.9 grammes in the liter. This quantity, or 
roughly 17 grammes, is weighed off and dissolved in 900 c.e. of a 
25 per cent, solution of nitric acid ; as the acid must be present in 
excess, the solution is purposely made too strong. To this solution 
50 c.c. of the liquor ferri sulphurati oxydati are added. The solu- 
tion is then brought to the proper strength by titration of a known 
number of cubic centimeters of a one-tenth normal solution of 
hydrochloric acid and correcting as usual. 

2. The ammonium sulphocyanide solution. A normal solution of 
ammonium sulphocyanide contains 75.98 grammes (molecular 
weight) per liter, and a decinormal solution 7.598 grammes. This 
quantity, or roughly 8 grammes, is dissolved in about 900 c.c. of 
water and the solution brought to the proper strength by titrating a 
known number of cubic centimeters of the silver nitrate solution, 
when each cubic centimeter should correspond to 1 c.c. of the silver 
solution — i. e., to 0.00365 gramme of hydrochloric acid. It is 
corrected as described elsewhere. 

Method. — 1. To determine the total amount of chlorine present : 
10 c.c. of filtered gastric juice — Martins and Liittke make use of 
the unfiltered gastric contents — are measured into a small flask 
bearing a 100 c.c. mark, and treated with an excess of the one-tenth 
normal solution of silver nitrate. Experience has shown that 20 c.c. 
arc sufficient. The mixture is agitated and allowed to stand for ten 
minutes. Distilled water is then added to the 100 c.c. mark; the 
mixture is agitated once more and filtered through a dry filter into 
a dry beaker. Fifty c.c. of the filtrate are titrated with the one- 
tenth normal solution of ammonium sulphocyanide until the blood- 
red color which appears upon the addition of every drop — due to 
the formation of ferric sulphocyanide — no longer disappears on 
stirring. By multiplying the number of cubic centimeters of the 
ammonium sulphocyanide solution used by 2 (the number of cubic 
centimeters that would have been necessary for the precipitation <»{" 
the excess of silver in 100 c.c.) and deducting the result from the 
number of cubic centimeters of the one-tenth normal solution of 
silver nitrate employed, viz., 20, the number of cubic centimeters 
of the latter solution is found which was necessary to precipitate 
the chlorine in 10 c.c. of the gastric juice. As 1 c.c. of the solu- 
tion represents 0.0036 gramme of hydrochloric acid, it is only nec- 
essary to multiply this figure by the number of cubic centimeters 
used in precipitation of the chlorine. The resulting value. T, 
expresses the total amount of chlorine present. 



172 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

As a general rule, it is not necessary to decolorize the gastric 
juice. If desired, however, 5 to 15 drops of a 5 per cent, solution 
of potassium permanganate may be added to the 10 c.c. employed, 
after the mixture has stood for ten minutes. 

2. Determination of the amount of chlorine in combination with 
inorganic bases, F. Ten c.c. of the filtered gastric juice are 
carefully evaporated to dryness in a platinum crucible, on a water- 
bath or upon a plate of asbestos, in order to avoid sputtering (as the 
heat applied in the process of incineration is not very intense, a 
porcelain crucible may also be employed). The residue is then care- 
fully incinerated over an open flame, the process being carried only 
to the point when the organic ash no longer burns with a luminous 
flame. Intense heat should be avoided, as the chlorides are volati- 
lized upon the application of red heat. On cooling, the ash is 
moistened with a few drops of distilled water and mixed with a 
stirring-rod, when the residue is extracted in separate portions with 
100 c.c. of hot distilled water and filtered. This amount is usually 
sufficient to dissolve all the chlorides present. If any doubt should 
exist, however, it is only necessary to add a drop of the silver solu- 
tion to a few drops of the last portion of the filtrate : the formation 
of a cloud, referable to silver chloride, will necessitate still further 
washing. The whole filtrate is then treated with 10 c.c. of the one- 
tenth normal solution of silver nitrate, and the amount consumed 
in the precipitation of the chlorides determined by titration with 
the one-tenth normal solution of ammonium sulphocyanide, as de- 
scribed above. The hydrochloric acid present in combination with 
inorganic bases is thus determined. The difference between the 
amount of hydrochloric acid in combination with inorganic bases 
and the total amount of chlorine in terms of hydrochloric acid will 
then indicate the amounts of the free and of the combined hydro- 
chloric acid, which are termed L and C, respectively ; hence 
T-F=L + a 

3. The total acidity in terms of hydrochloric acid is further de- 
termined according to the method given elsewhere (see page 157) and 
indicated by the letter A. The difference between the total acid- 
ity and the amount of free and combined hydrochloric acid will 
represent the amount of organic acids and acid salts, ; hence 
= A — (L + C). 

The free hydrochloric acid finally is determined according to the 
method of Topfer. The difference between the value thus found 
and that expressing the amount of free and combined hydro- 
chloric acid will indicate the amount of the latter; hence (L -f- C) 

— l= a 

Leo's Method. 1 — This method is based upon the observation that 
calcium carbonate combines with free and combined hydrochloric acid 

1 Leo. Centralbl. f. d. med. Wiss., 1889. vol. xxvii. p. 481. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 173 

at ordinary temperatures to form neutral calcium chloride, while the 
acid phosphates arc not affected. It is thus clear thai by determin- 
ing the total acidity of the gastric juice, and deducting from this 
the acidity referable to acid salts, the amount of the physiologically 
active hydrochloric acid — i, €., of the free and combined hydrochloric 
acid — is obtained. 

As it has been shown that in the presence of calcium chloride 
(formed, as indicated above, upon the addition of calcium carbonate), 
owing to the formation of calcium monophosphate — CaHP0 4 , twice 
the quantity of sodium hydrate is taken up, it is necessary to make 
the first titration also after the addition of an excess of calcium 
chloride 1 . 

Reagents required : 

1. A one-tenth normal solution of sodium hydrate. 

2. A 1 per cent, alcoholic solution of phenolphthalein. 

3. A concentrated solution of calcium chloride. 

4. Chemically pure calcium carbonate. The purity of the salt 
may be tested by stirring a small piece with water ; the solution 
should not color red litmus-paper blue. A solution of the salt in 
dilute hydrochloric acid should not yield a precipitate when treated 
with sulphuric acid. 

Method. — Organic acids that may be present are first removed 
by shaking with ether, 50 to 100 c.c. being required for each 10 c.c. 
of gastric juice. The total acidity of the gastric juice is then de- 
termined in 10 c.c. of the filtered liquid after the addition of 5 c.c. 
of the concentrated solution of calcium chloride, the result being 
termed A. 

The acidity referable to the presence of acid phosphates is deter- 
mined as follows : 15 c.c. of filtered gastric juice are treated with a 
pinch of dry and chemically pure calcium carbonate ; the mixture is 
thoroughly stirred, and passed at once through a dry filter. Ten 
c.c. of the filtrate, from which the carbon dioxide is expelled by 
means of a current of air, are then treated with 5 c.c. of the 
calcium chloride solution and titrated as above, the resulting value 
being termed P. A — P is hence equivalent to L -\- C. The 
value of C can then be ascertained by determining the acidity 
referable to free hydrochloric acid according to Topfer's method, and 
deducting the value found from L -f C. 

This method is sufficiently accurate for practical purposes, and has 
the advantage of not requiring the expenditure of much time. 

The Ferments of the Gastric Juice and their Zymogens. 

Pepsin and Pepsinogen. — According to our present knowledge, 
the zymogen of pepsin, viz., pepsinogen or propepsin, and not pepsin 
itself, is secreted by the chief cells of the fundus glands. This view 



174 TEE GASTRIC JUICE AND GASTRIC CONTENTS. 

is based upon the observation that an aqueous extract of the mucous 
membrane of the stomach of a fasting animal recently killed does 
not lose its digestive power for a considerable length of time when 
treated with a 1 per cent, solution of sodium carbonate at a tempe- 
rature of from 38° to 40° C, whereas pepsin itself is thus rapidly 
destroyed. It is natural then to conclude that the glands of the 
stomach do not contain pepsin, but some other substance during the 
process of fasting, which is capable of resisting the action of sodium 
carbonate, and which can be transformed into pepsin by the addition 
of hydrochloric acid. This substance has been termed pepsinogen or 
propepsin. As a rule, pepsin is obtained only from the mucous 
membrane of the digesting organ, while at other times the physio- 
logicallv inactive zymogen is found. As the zymogen, moreover, is 
probably always present together with pepsin in the gastric juice 
obtained from healthy individuals during the process of digestion, it 
is not clear whether the transformation of the zymogen into its fer- 
ment takes place in the body of the cell or after secretion. There is 
evidence to show, however, that the latter view is correct. 1 

This is not the place to enter into a detailed consideration of the 
various properties of pepsin, and it will suffice to say that the activity 
of the ferment is destroyed by even very dilute solutions of the 
alkaline carbonates. The same result is reached by exposing a watery 
solution of pepsin to a temperature of i : C .. while in a dry state 
a temperature of 100° C. will not destroy its activity ; this is shown 
by the fact that a specimen of pepsin thus treated is, on cooling, still 
capable of digesting albumins in the presence of hydrochloric acid. 

'While pepsin is capable of digesting albumins in the presence of 
other acids, viz., phosphoric, sulphuric, oxalic, acetic, lactic, and 
salicylic acids, the solutions must be stronger than in the case of 
hydrochloric acid. With lactic acid, for example, a satisfactory 
result is reached only with a concentration of from 12 to 18 pro mille, 
while of hydrochloric acid 2 to 4 pro mille are sufficient. Larger or 
smaller amounts do not act so promptly. 

Very important from a practical standpoint is the fact that but 
small quantities of pepsin are required to digest large amounts of 
albumin. Petit 2 thus claims that a pepsin preparation from his 
laboratory was capable of dissolving 500,000 times its weight of 
fibrin in seven hours. This property possessed by pepsin, of doing 
an amount of work that is widely out of proportion to the amount 
of ferment present, is common to all ferments, and is dependent upon 
the fact that the ferment itself undergoes no change during the 
process. 

Figures expressing the exact quantity of pepsin or of its zymogen 
produced in the twenty-four hours are lacking, and inferences can 

1 C. E Simon. Physiological Chemistry, Lea Bros. & Co., 1901. 

2 Petit, •' Etude sur les ferments digestife, 7 ' Jour. de. Therap., 1890. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. J 75 

hence only be drawn as to the physiological activity of the ferment 
from the rapidity with which given amounts of albuminous material 
are digested. This, however, depends to a large extent upon the 
nature and concentration of the free acid present. Under normal 
conditions 25 c.c. of gastric juice will dissolve 0.05 to 0.0G gramme 
of serum-albumin in one hour, the same amount of coagulated egg- 
albumin in three hours, and a like amount of fibrin in one hour and 
a half. 

As abnormalities in the circulation and innervation of the stomach 
apparently do not influence the production of pepsin, or rather of its 
zymogen, a diminution in the degree of peptic activity, or its total 
absence, may be referred directly to disease of the stomach itself, 
viz., its glandular apparatus. The determination of the presence or 
absence and relative amount of pepsin in the gastric juice, hence, 
furnishes more useful information than the recognition of the presence 
or absence of free hydrochloric acid. 

As pepsin is formed from pepsinogen through the agency of a free 
acid, its presence, in the absence of organic acids in notable quan- 
tities, indicates at once the presence of hydrochloric acid. It may 
be said, vice versa, that if free hydrochloric acid is present in the 
gastric juice, and the latter digests albumins, pepsin also will be 
found. Should the zymogen alone be present, digestion will take 
place only upon the addition of an acid, while an absence of diges- 
tion upon the addition of hydrochloric acid indicates the absence of 
both pepsin and its zymogen. At times, though rarely, a " gastric 
jnice" is met with which is capable of digesting albumin in the 
absence of hydrochloric acid, owing to the presence of pancreatic 
juice — a point which is important, both from a diagnostic and a 
prognostic point of view. 

In the differential diagnosis of a chronic gastritis and a neurosis, 
or a dyspeptic condition referable to hyperemia of the gastric mucous 
membrane, the demonstration of the presence of the zymogen in the 
absence of hydrochloric acid may, at times, be very important, bear- 
ing in mind the fact that circulatory and nervous disturbances 
apparently do not influence the production of pepsinogen. An entire 
absence of the latter would, of course, warrant the diagnosis of 
complete anadeny of the stomach. 

Tests for Pepsin and Pepsinogen. — Test for the Enzyme. — If the 
presence of free hydrochloric acid has previously been ascertained, 
25 c.c. of filtered gastric juice are set aside and kept at a tempera- 
ture of from 37 u to 40° C., a bit of coagulated egg-albumin, fibrin, 
or serum-albumin being added. In order to permit of a comparison 
of results, the same amounts should always be taken ; 0.05 to 0.0(3 
gramme of egg-albumin, as has been shown, ought, under physiolog- 
ical conditions, to be digested in three hours. 

Test for the Zymogen. — Should hydrochloric acid be absent, the 



17C THE 1ASTBIC JUICE ASIt GASTRIC CONTENTS 

test Is made in the same manner, after the addition of from 3 tc " 
drops of the officinal solution of hydrochloric acid to 25 c.c. of the 
filtrate. Under such conditions usually pepsinogen alone is found. 

Quantitative Estimation. — Of Pepsin. — Accurate methods for the 
quantitative estimation of pepsin are unknown, and relative values 
only can be obtained. Most convenient is the method suggested bv 
Hamnierschlag. 1 Three Esbach's tubes ( albuminimeters ) are em- 
ployed. Tube A is filled to the mark U with a mixture of 10 e.c. 
of a 1 per cent, solution of serimi-albuinin in 0.4 per cent, of hydro- 
chloric acid and o c.c. of filtered gastric juice. The second tube, 
B, which is the standard, is likewise filled to the mark U, but 
gramme of pepsin is added to the serum solution, instead of the 
gj -Trie juice. The third tube. C ntains merely a mixture of the 
serum solution and 5 c.c. of water. After having been kept in the 
thermostat for one hour, at a temperature of 37 c '_.. Esbach's 
reagent is added to each tube to the mark R. After standing for 
: iTty-four hours the amount of precipitated albumin is read off, 
and the difference between that in tube A and tube C compared 
with that in tube B. 

Of Pepsinogen. — In order : estimate the amount of pepsinogen 
the method of Boas may be employed. 7 this end, the gastric 
juice is diluted with distilled water in varying proportions, such as 
1 : 5, 1 : 10, 1 : 20, etc. A known quantity of coagulated albumin 
is added to each specimen, as also 1 or 2 drops of an officinal 
solution of hydrochloric acid, for each 1 mployed. Tl 

tubes are kept at a temperature of from 87° t - ' when the 
degree of dilution is noted at which the bit of egg-albumin is still 
dissolved. The greater the degree of dilution at which digestion 
still takes place, the greater the amount of pepsin or of its zymogen 
present. 

If it is desired to exclude definitely the presence of pepsin and 
pepsinogen in the stomach, the method of Jaworski should be em- 
ployed. To this end, about 200 cc. of a decinormal solution : 
hydrochloric acid are poured into the stomach through a tube and 
aspirated after one-half hoor. If the fluid removed contains no 
pepsin, the absence of both the enzyme and its gen may be 

inferred. 

The Milk -curdling Ferment and its Zymogen, viz., Chymosin 

and Ghymosrnogen. — A great deal of what has been said al 

regarding pepsio and its zymogen also holds good for chymosin and 

ro-enzynie- The pro-enzyme thus also appears to l>e formed by 

the cell, as a neutral aqueous extract of the mucous membrane of the 

- >ntain the ferment, but the zymogen, 

the ferment resulting only when the latter is treated with a free acid. 

It differs from pepsin in that it can exert its physi _ieal activity 

' HamroerecMag. Wien. med. Presse, 1894, toL xxxt. p. 1654. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 177 

in feebly acid, neutral, and even feebly alkaline solutions. Exposure 
of an active solution of chymosin to gastric juice containing 3 pro 
mille of free hydrochloric acid, moreover, at a temperature of from 
37° to 10 C, leads to it- destruction. 

Its specific action is exerted upon milk, or lime-containing dilu- 
tions of casein, which arc coagulated in neutral or feebly alkaline 
solutions. 

In this connection it is important to note that the addition of a 
tew cubic centimeters of a solution of calcium chloride, or any other 
soluble lime salt, results in a transformation of the zymogen into the 
physiologically active ferment, and that hydrochloric acid, while it 
normally causes such transformation, is not absolutely necessary in 
the presence of calcium chloride. 

Under physiological conditions chymosin and its zymogen are 
always present in the gastric juice. In disease the inferences that 
may be drawn from a quantitative estimation of the ferment and its 
zymogen have been well formulated by Boas, 1 to whom we are espe- 
cially indebted for a great deal of valuable information in this con- 
nection : 

1. Xot withstanding the absence of free hydrochloric acid, chymo- 
sin may be present, although in minimal traces — i. e., demonstrable 
with a dilution of from 1 : 10 to 1 : 20 (see method on page 178). 

2. In the absence of free hydrochloric acid the zymogen may still 
be present in normal amounts — i. e., demonstrable with a dilution 
of from 1 : 100 to 1 : 150. The presence of the zymogen, especially 
when repeatedly observed, probably always permits of the conclusion 
that we are not dealing with an organic disease of the stomach, but 
with a neurosis or a hyperaamic condition of the mucous membrane 
referable to disease of other organs. 

3. The zymogen may occur in moderately diminished amount, 50 
per cent, only being present. This is usually owing to the existence 
of a gastritis w r hich has not reached its highest degree of severity. 
The nearer the amount of zymogen approaches the normal, the 
greater will be the probability of an ultimate recovery under suit- 
able treatment. 

4. The amount of the zymogen is greatly diminished (dilutions 
of 1 : 10 to 1 : 25 yielding a negative result) or may be absent alto- 
gether. In cases of this kind a severe and usually incurable gas- 
tritis exist-, either primary or occurring secondarily to carcinoma, 
amyloid degeneration, etc. 

5. In conditions 1, 2, and 3, the re-establishment of the secretion 
of hydrochloric acid may be attempted with some prospect of success 
by means of stimulating remedies. 

These conclusions are based upon the employment of Ewald's 

1 Boas. Centralbl. f.d. mod. Wiss., 1887, vol. xxv. p. 417; and Zeifc f. klin. Med., 1888, 
vol. xiv. p. 240. See also J. Friedemvald. Ifed. News. 1895. 

12 



178 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

test-breakfast, and cannot be applied to observations made after 
other test-meals, without previous studies in this direction. 

Testing for the presence of chymosin and its zymogen, moreover. 

is of decided value in cases in which alkaline material is vomited, 
and where we may he called upon to decide whether this contains 
constituents of the gastric juice or not. 

Tests for Chymosin and Chyniosinogen. — Test for the Enzyme. 
— Five to 10 c.c. of milk are treated with from 3 to 5 drops of 
the hit-red gastric juice and kept at a temperature of from 37° 
to 4u : C. for ten to fifteen minutes. If coagulation occurs during 
this time, it may definitely he concluded that the enzyme is present. 

Test for the Zymogen. — The milk is treated with 10 c.c. of the 
filtered and feebly alkalinized gastric juice and with 2 or 3 c.c. of a 
1 per cent, solution of calcium chloride. The mixture i.- kept at a 
tempera ture of from 37 : to 40 c C. when in the presence of the 
zymogen the formation of a thick cake of ca-ei'n will be observed 
to occur within a few minutes. 

Quantitative Estimation, — Of the Enzyme. — Thi- is based upon 
the fact that on gradually diluting a specimen of gastric juice a 
point finally is reached at which a chymosin reaction can no longer 
be obtained, the value ?ing 3 of course, a relative one. Under phys- 
iological conditions a positive reaction can still be observed with a 
degree of dilution varying between 1 : 30 and 1 : 4<j. 

The gastric juice is neutralized with a very dilute solution of 
sodium hyelrate. Tubes are then prepared containing from 5 to 10 
c.c. of the gastric juice, diluted in the proportion of 1 : 10, 1 : 20, 
1 : 30, etc.. to which an ecjual amount of neutral or amphoteric milk 
is added. The tubes, properly labelled, are kept at a temperature 
of from 37 c to 40° C. and the degree of dilution noted at which 
coagulation still occurs. 

Of the Zymogen. — The gastric juice is rendered feebly alkaline 
and tube- are prepared containing equal amounts of milk and 
gastric juice, the latter variously diluted, as above directed : the 
examination is then carried on in the same manner, Normally a 
positive reaction i- obtained with a elilutie>n varying between 1 : 150 
and 1 : 1 <"><'•. Allowance must, of course, be made for the amount 
of fluid which i- added during the process of neutralization. 

The Products of Gastric Digestion. 

Digestion of the Native Albumins. — The first step in the- proc- 
ess of albuminous digestion in the stomach is one of swelling, 
which maybe observed when a flake of fibrin, for example, is pis 

in era s trie juice and the temperature maintained between 37° and 
40 c C. Very soon simple solution takes place, which i- followed 

by the process of " denaturization," as Xeumeister terms it. in 
which the native albumins are transformed into acid albumins or 



CHEMICAL EXAMINATION OF THE CASTRIC JUICE. 179 

syntonins, owing to the continued activity of the hydrochloric acid 
and pepsin. The pepsin, however, acts only as an adjuvant to the 
acid, and hydrochloric acid alone is capable of effecting the same 
result. But while in the absence of pepsin more concentrated solu- 
tions of the acid and a higher temperature are required, the tem- 
perature of the body and the amount of hydrochloric acid secreted 
by the stomach are sufficient when pepsin is present. Pepsin, in 
the absence of free hydrochloric acid, is perfectly inert. 

The " denaturization " of the native albumins is followed by a 
splitting up of the albuminous molecule and a process of hydration, 
the so-called primary albumoses being the first products thus formed. 
During the further process of digestion the deutero-albumoses then 
result, and from these the peptones, to which, in contradistinction 
to the peptones formed during the process of pemcreatic digestion, 
the term amphopeptone has been applied by Kuhne. 

Digestion of the Proteids. — The digestion of casein, which 
belongs to the class of nucleo-albumins, differs from the process 
described. The casein of the milk is present in solution as a neutral 
calcium salt, and as it has the character of a polybasic acid, calcium 
chloride and the corresponding acid casei'11 salt will result in the 
presence of the hydrochloric acid of the stomach ; still later, when 
more hydrochloric acid has been secreted, insoluble casein, as such, 
will be found. While the acid is thus capable of causing the pre- 
cipitation of casein, it has also been shown that the same result may 
be reached in the absence of hydrochloric acid. According to 
Hammarsten, this is brought about in consequence of the hydrolytic 
action on tlu part of the chymosin, the calcium salt of paracasein 
(cheese), and a small amount of an album ose-like posset-albumin 
being formed. This latter process is now supposed to take place in 
the stomach after the hydrochloric acid has previously transformed 
the neutral into the acid casein salt. When this stage is reached the 
paracasein is decomposed into an albumin and an insoluble nuclein. 
The albumin is then further digested as described ; a hetero-albumose, 
however, does not result. The remaining proteids, such as haemoglo- 
bin, glucosides, etc., are similarly acted upon by the gastric juice, and 
are first split up into the corresponding albumins and their pairlings. 
The albuminous radicles are then digested, as described. 

Digestion of the Albuminoids. — Of the albuminoids, only col- 
lagen and elastin undergo digestion in the stomach, gelatoses and 
elastoses being formed during the process, while keratin passes off 
undigested. Hetero-albumoses, however, are formed from neither 
collagen nor elastin, but merely proto-albnmoses, which in turn are 
transformed into deutero-albumoses, and these into peptone. 

Digestion of the Carbohydrates. — The secretion of the stomach 
itself is not capable of digesting carbohydrates. There appears to 
be no doubt, however, that a transformation of starches into sugar 



180 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

takes place during the earlier stages of digestion. This is owing to 
the continued action of the ptyalin of the saliva (see page 139) in 
the stomach, which proceeds until the amount of hydrochloric acid 
secreted reaches 0.01 per cent, or more, it being remembered that the 
transformation of starches into sugar takes place best in a neutral 
or feebly alkaline medium. 

The question whether or not a diastatic ferment occurs in the 
mucus secreted by the stomach itself is unimportant, as cases have 
but rarely been observed in which there was an absence of ptyalin 
from the saliva. 

As indicated in the chapter on the Saliva, a number of intermediary 
products are formed in the transformation of starch into sugar, of 
which an idea may be had from the accompanying table : 

Starch. 

Amidulin. 



! 

Erythrodextrin. Maltose. 

I . i 

Achroodextrin a Maltose. 

I . I 

Achroodextrin /? Maltose. 

I I 

Achroodextrin y (maltodextrin) Maltose. 

1 I 

Maltose. Maltose. 

In the mouth this transformation is effected very rapidly in the 
case of certain starches, such as corn-starch and rye-starch, and it is 
possible to demonstrate the presence of sugar after from two to six 
minutes. Potato-starch, on the other hand, requires a much longer 
time, viz., from two to four hours. This difference is entirely de- 
pendent upon the varying degree of resistance offered to the action 
of the saliva by the enclosing envelope of cellulose, as is apparent 
from the fact that a paste made from potatoes is digested just as 
rapidly as one made from rye. 

For practical purposes, the digestion of carbohydrates in the 
stomach may be disregarded as insignificant. 

Fats are not digested in the stomach. 

From the above considerations it is apparent that under physio- 
logical conditions a mixture of various products is met with in the 
stomach at the height of digestion, and it might be expected that 
from a preponderance of the one over the other definite and valuable 
conclusions as to the digestive power of the organ could be reached. 
While this is true in a certain sense, the quantitative methods of 
analysis that would have to be employed in order to obtain definite 
data are as yet too complicated for the purposes of the clinician, and 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. L81 

from the simple qualitative tests not much information can be de- 
rived. The recognition of the presence of peptones would thus 

merely indicate the presence of hydrochloric acid and pepsin in a 
general way, as peptones may be formed in the absence of hydro- 
chloric acid and in the presence of organic acids, which may be found 
in pathological conditions. A portion of the albumin of milk, eggs, 
meat, etc., is, moreover, already peptonized during the process of 
boiling. It is not surprising then that peptones may be demonstrated 
in practically every specimen of gastric contents. 

A large amount of syntonin and primary albumoses in the presence 
of a feeble peptone-reaction must, of course, be regarded as abnormal, 
pointing to a defective secretion of either hydrochloric acid or the 
enzymes, or of both. The same may be said to hold good when a 
pronounced peptone-reaction disappears upon the removal of syntonin 
and the primary albumoses. 

So far as the examination for the products of carbohydrate diges- 
tion is concerned, it may be stated, as a general rule, that in the 
presence of a normal amount of hydrochloric acid erythrodextrin can 
usually be demonstrated toward the end of gastric digestion, while 
achroodextrin is nearly always obtained at that time when free hydro- 
chloric aeid is absent, so that the tests for the presence of these two 
bodies may be regarded as roughly indicating the presence or absence 
of free hydrochloric acid. Boas draws attention to the fact, however, 
that ptyalin may, at times, though rarely, be absent, when conclusions 
drawn from these tests as to the presence of hydrochloric acid would 
be erroneous. 

The tests for sugar in the gastric juice do not furnish any infor- 
mation of practical value. 

Analysis of the Products of Albuminous Digestion. 

In order to separate the various bodies referred to from each other 
the following procedure may be employed : 

The filtered gastric contents are carefully neutralized with a dilute 
solution of sodium hydrate, using litmus-paper to determine the re- 
action ; a small drop of the mixture is placed upon the paper from 
time to time during the addition of the sodium hydrate until no 
change in color is produced either on the vod or the blue paper. If 
syntonin is present, it will be precipitated, and can be collected on a 
small filter. Upon the addition of an excess of dilute acid or an 
alkali this precipitate will again be dissolved. The filtrate is feebly 
acidified by the addition of a few drops of a very dilute solution of 
acetic acid, treated with an equal volume of a saturated solution of 
common salt, and brought to the boiling-point. Any native albumin 
that may be present in solution is thus coagulated and can be filtered 
off on cooling. In the filtrate the albumoses and peptones remain. 
The presence of the former may be demonstrated by adding a few 



182 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

drops of nitric acid to a specimen, when a precipitate will form which 
dissolves upon the application of heat, and reappears on cooling; 
if necessary, the specimen may be diluted. 

Should the deutero-albumoses of vitellin or myosin be present, 
however, this test yields a negative result, and a precipitate only 
occurs when the solution, acidified with nitric or acetic acid, is com- 
pletely saturated with sodium chloride. 

The presence of primary albumoses may be established by adding 
pieces of rock-salt to the neutral solution, when a precipitate occurs. 
The albumoses may roughly be separated from the peptones by satu- 
rating the acidified filtrate just obtained with pulverized ammonium 
sulphate, whereby the albumoses are precipitated almost entirely. 
A small portion of deutero-albumoses, however, which resulted from 
the proto-albumoses, remains in solution and passes into the filtrate, 
which also contains all of the amphopeptone. In the filtrate this 
may be demonstrated as follows : a concentrated solution of sodium 
hydrate is added until all the ammonium sulphate has been trans- 
formed into sodium sulphate, and a slight excess of the hydrate is 
present ; care should be had, however, that the temperature does 
not rise too high, by immersion in cold water. The sodium sulphate, 
which separates out during this process, is allowed to settle. A 2 
per cent, solution of cupric sulphate is then carefully added drop 
by drop, to a specimen of the supernatant fluid, when in the pres- 
ence of peptones a rose to a purplish-red color will develop. 

To obtain the peptones, the filtrate is diluted with an equal volume 
of water, neutralized, and then treated with a solution of tannic acid, 
care being taken to avoid an excess, as otherwise the peptone precipi- 
tate is partly dissolved. 1 

Tests for the Products of Carbohydrate Digestion. 

Starch may be recognized by the fact that it strikes a blue color 
with a solution of iodo-potassic iodide, while the same solution gives 
a violet or mahogany brown with ervthrodextrin. To this end, it 
is only necessary to add a drop or two of LugoPs solution to a few 
cubic centimeters of the filtered gastric juice. The presence of 
achroodextrin may be inferred if no change in color occurs upon 
the addition of the reagent. 

Maltose and dextrose, which both react with Fehling's solution 
and undergo fermentation, differ from each other in the fact that 
the former does not reduce BarfoecVs reagent on boiling. This is 
prepared by adding 1 per cent, of acetic acid to a 0.5 to 4 per cent, 
solution of cupric acetate. The rotatory power of maltose is about 
three times as strong as that of dextrose; («) D = 150.4, as com- 
pared with 52.5. 

1 For a more detailed account of the chemistry of digestion and the analysis of the 
resulting products, see C. E. Simon, Physiological Chemistry, Lea Bros. & Co., 1901. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 183 

Lactic Acid. 

Mode of Formation and Clinical Significance. — It was for- 
merly thought that the acidity of the gastric juice was referable to 

the presence of lactic acid, as this can always he demonstrated in 
the beginning of the process of digestion. The hydrochloric acid 
was then supposed to result from the action of the lactic acid upon 
the chlorides of the food. That this view is erroneous C. Schmidt 1 
succeeded in demonstrating beyond a doubt, as has been shown on 
page loo. An explanation of the presence of lactic acid suggested 
itself when Miller found that in the mouth various bacteria normally 
occur which are capable of forming lactic acid from sugar, and that 
from the gastric contents a number of bacteria can be isolated which 
are capable of causing acid fermentation in sugar-containing media. 
There would, hence, be nothing surprising in the constant occur- 
rence of lactic acid, as the two principal factors necessary for its 
formation are always present after the ingestion of an ordinary 
meal, viz., carbohydrates and bacteria capable of causing lactic acid 
fermentation. The absence of the lactic acid during the later stages 
of digestion was, furthermore, explained by the fact that lactic acid 
fermentation caases in the presence of from 0.7 to 1.6 pro mille of 
hydrochloric acid — -i. e. f in the presence of amounts of hydrochloric 
acid which are found in tha normal gastric juice. 

The normal occurrence of lactic acid in the stomach was, until 
recently, regarded as an established fact. But at this stage Martins 
and Liittke, employing the method already described, found " that the 
accuratsly determined curve of acidity referable to hydrochloric acid 
coincided in all respects, even at the beginning of the process of 
digestion, with the curve referable to the total acidity," so that 
lactic acid as a physiological constituent could not have been present. 
Recent researches of Boas, 2 moreover, appear to prove beyond a 
doubt that in physiological conditions no appreciable amounts of 
lactic acid are formed during the process of digestion, and that the 
lactic acid found after an ordinary meal has been introduced into 
the stomach as such. That lactic acid is actually present in the 
various kinds of bread has definitely been proved, and it is, hence, 
not parmissible to make use of any test-meal containing lactic acid 
when the question as to its formation in the stomach is to be con- 
sidered. For these reasons Boas suggests the use of simple oatmeal- 
soup to which salt only has been added. For practical purposes 
this i> probably not always necessary, as the small amount of lactic 
acid found after Ewald's test-breakfast may usually be disregarded ; 
an increased amount can be referred directly to pathological con- 
ditions. 

1 Lor. cit. 

2 J. Boas, " Ueber A. Vorkoninicn v. Milchsaure im Gesunden u. Kranken MageD," 
Zeit. f. klin. Med., 1894, vol. xxv. p. 285. 



184 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

The fact that the lactic acid disappears, or is at least no longer 
demonstrable, at the height of digestion. Boas refers to a resorption 
or a earrymg-oif of the acid introduced, on the one hand, or to an 
interference of the hydrochloric acid with the delicacy of the reagent 
usually employed — i. e., Ulfelmann's reagent — on the other. Patho- 
1 .i-ally the same rule may be said to hold good, as Boas was tin- 
able to demonstrate its presence after the exhibition of his te-t-meal 
in the most diverse diseases of the stomach, viz.. chronic gastritis. 
atony and dilatation referable to myasthenia, or pyloric sten<:-is 
following ulcer, etc. Mere traces, which were occasionally observed, 
: - significance, and possibly referable to lactic acid femienta- 
tion having taken place in the inouth. In all the cases examined. 
: reover, no organic acids could be demonstrated by the method of 
Hehner-Seemann (see page 192 . 

It is apparent then that notwithstanding stagnation of the gastric 
contents and the absence of free hydrochloric acid in normal amounts, 
lactic acid is not necessarily formed in the stomach, even in the 
presence of carbohydrates. In only one disease of the stomach was 
lactic acid found in notable quantities, viz.. in carcinoma. This ob- 
servation is in accord with the fact that Ulfelmann's test here yields 
a marked reaction — /'. e., a deep-lemon or a canary-yellow color — 
even upon the addition of bnt a lew drops of the gastric juice, while 
in the benign affections only a tale-yellow, brownish, or grayish 
c loi is i >btained. 

Boas 5 test-meal should be given the evening before the examina- 
tion, the stomach having previously been washed free from all 
remnant- : : d : the remaining contents are obtained the next 
morning. 

In an analysis of fourteen cases • : carcinoma Boas was able to 
demonstrate the presence of lactic acid in amounts varying between 
1.22 and 3.82 pro mille in all cases but one, while in other diseases 
after the ingestion of Ewald's test-breakfast only 0.1 to 0.3 pro 
mille could be obtained. 

Unfortunately, recent investigations have shown that notable 
amounts of lactic acid may also be found in gastric anadeny. and in 
cases of dilatation referable to benign causes. Such cases, however, 
are rare, and it may safely be stated that the presence of large 
amounts of lactic acid will almost invariably justify the diagnosis of 
carcinoma of the stomach. 1 

That stagnation of the gastric contents and the absence of free 

hydrochloric acid alone an I pable of causing the formation of 

lactic acid has - «n, and it is, hence, difficult to explain why in 

ally only lactic acid fermentation should occur. 

l J.BLdeJong Milchsaure u. ihre klinische Bedentnr.s." Arch. 

_ ink., vol. ii. p. 53. J. Frierlenwald. " The Significance of the Presence 
of Lactic Arid in xhf Stomach." N. Y. Med. Jour.. 1895. Rosenhaim u. Eichrer. '" Ueher 
Milehsaurehildung im Magen," Zeit. f. klin. Med., vol. xxviii. p. 505. 



(1) 


^H, 


uA 


+ 


H.,0 


(2) 


C 1 .,Ho 2 () u 


■ 


H 2 


(3) 


SiCeH, 


A 







CHEMICAL EXAMINATION OF THE GASTRIC JUICE. L85 

Whether the malignant growth Itself must be regarded as one of the 
principal factors in this connection, as Boas suggests, must still re- 
main an open question. 

Owing to the interest which attaches to this subject, it may not 
be out of place to refer briefly to the following observation of Koch : 
In a case in which ulcer of the stomach existed, the hydrochloric 
acid suddenly disappeared and gave place to lactic acid, which then 
steadily increased in amount from week to week. A tumor could 
not he demonstrated on physical examination. Soon after, the patient 
died, and at the autopsy a carcinoma of the stomach was found upon 
the base of the pyloric ulcer. An exploratory operation should hence 
be made whenever notable amounts of lactic acid can repeatedly be de- 
monstrated in the stomach contents after the incjestion of Boas'' test-meal. 
Negative results, however, do not exclude the existence of carcinoma. 

The formation of lactic acid from starch may be represented by 
the following equations : 

Ci.,H 2 .,O u (milk-sugar). 
2C 6 H 12 6 (glucose). 
4C 3 H 6 3 (lactic acid). 

It should, finally, be mentioned that only that form of lactic acid 
which results from fermentative processes is of interest in this con- 
nection, and not the sarcolactic acid contained in meat. 

Tests for Lactic Acid. — For the reasons indicated, Boas' test- 
meal (see page 150) should be employed whenever it is desired to test 
for lactic acid in the gastric contents. If the ease under examina- 
tion shows well-marked symptoms of stagnation, the stomach should 
be washed out completely in the evening, the soup then given, and 
the gastric contents procured the next morning, before any food or 
liquid is taken. Otherwise the test-meal may be given in the morn- 
ing on an empty stomach, without previous lavage, and the contents 
examined one hour later. 

Uffelmann's Test. 1 — Heretofore Uffelmann's reagent was quite com- 
monly employed in testing for lactic acid, but everyone who has 
had occasion to make frequent use of this reagent in clinical work 
must have been struck with the uncertainty of the results so often 
obtained. In a large majority of the cases thus examined, particu- 
larly if Ewald's test-breakfast is employed, a characteristic reaction 
— i. e., the occurrence of a lemon or canary-yellow color — is not 
seen, notwithstanding the presence of lactic acid, but a pale-yellow, 
brownish, grayish-white, or even gray color is obtained instead, often 
leaving in doubt whether lactic acid is present or not. Aside from 
doubtful results, the value of the test is greatly diminished by the 

1 rffelmarm. Deutsch. Arch. f. klin. Med., 1880, vol. xxvi.; and Zeit. f. kliu. Med., 
vol. viii. p. 392. 



186 THE GASTRIC JUICE AST) GASTRIC CONTENTS. 

fact that glucose, acid phosphates, butyric acid, and alcohol give the 
same reaction, and that in the presence of such amounts of hydro- 
chloric acid as are found at the height of normal digestion lactic 
acid is not indicated by the reagent. All these difficulties have long 
been appreciated, and in order to obviate at least some of them it 
was proposed to apply the test to an aqueous solution of the ethereal 
extract of the gastric contents : 

To this end, 5 or 10 c.c. of the filtered gastric juice are extracted 
by shaking with from 50 to 100 c.c. of neutral sulphuric ether in a 
stoppered separating-funnel for about twenty or thirty minutes ; the 
ethereal extract is then evaporated on a water-bath or the ether 
distilled off [no flame). The residue is taken up with from 5 to 
10 c.c. of distilled water, and tested as follows : three drops of a 
saturated aqueous solution of ferric chloride are mixed with three 
drops of a concentrated solution of pure carbolic acid and diluted 
with water until an amethyst-blue color is obtained : to this solution 
a portion of the ethereal extract is added, when in the presence of 
only 0.1 per cent, of lactic acid a lemon or canary -yellow color is 
obtained. 

Kelling's Method. 1 — Five or 10 c.c. of gastric juice are diluted 
with from ten to twenty volumes of water and treated with one or 
two drops of a 5 per cent, aqueous solution of ferric chloride. In 
the presence of lactic acid a distinct greenish-yellow color is seen if 
the tube is held to the light. This test is more reliable than that 
of Uffelmann, as a positive reaction is obtained only in the presence 
of lactic acid. 

Strauss' Method.- — Instead of evaporating the ether as in the 
above method, the ethereal extract may be directly examined by 
shaking with a freshly prepared solution of ferric chloride, as sug- 
gested by Fleischer. Making use of this principle. Strauss has 
constructed an apparatus (Fig. 37) which may be found very con- 
venient, and which permits of roughly determining the amount of 
lactic acid present. The instrument is essentially a separating- 
funnel of 30 c.c. capacity, bearing two marks, of which the one 
corresponds to 5 c.c. the other to 25 c.c. The apparatus is filled 
with gastric juice to the mark 5. when ether is added to the 25 c.c. 
line. After shaking thoroughly, the separated liquids are allowed 
to escape by opening the stopcock until the 5 c.c. mark is reached. 
Pi -tilled water is then added to the 25 mark, and the mixture treated 
with two drops of the officinal tincture of ferric chloride, diluted in 
the proportion of 1 : 1 0. Upon shaking, the water will assume an 
intensely green color if more than 1 pro mille of lactic acid is pres- 
ent, while a pale green is obtained in the presence of from 0.5 to 1 

1 G. Kellins. " Ehocian im Maseninhalt : Zugleich ein Beitrag z. Uffelmann 'schen 
Milch^aurereasen*."' Zeit. f. physiol. Chem.. vol. xviii. 

- H. Strauss, "IVDer eine Modifikation d. Uffehnann'scken Eeaktion." Berlin, klin. 
Woeh.. 15PS. Xo. 37. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 187 



pro mille. The tincture of iron should be kept in a dark-colored 
dropping-bottle of about 50 c.c. capacity. 

Jt will be observed that only large amounts of lactic acid, which 
alone are of importance from a diagnostic point of view, are indi- 
cated by the apparatus. Small amounts, as those introduced with 
Ewald's test-breakfast, or referable to lactic acid 
fermentation in the mouth, are not indicated, so Fig. 37. 

that confusion as to the presence or absence of 
the acid can never arise. 

Boas' Method. 1 — In doubtful cases the follow- 
ing method should be employed, as with it, and 
following the exhibition of Boas' test-meal, all 
possible errors can be avoided. The stomach mast, 
however, be washed perfectly clean before the test- 
meal is introduced. It is my belief that some of 
the positive results which have been obtained in 
other diseases than carcinoma are referable to 
neglect in this particular point. Aldehyde is not 
infrequently found in the stomach contents when 
sarcinse are present in larga numbers, and may 
be mistaken for lactic acid, as I discovered to my 
regret not Ions: ago. 

Principle of the Method. — When a solution of 
lactic acid is treated with a strong oxidizing agent 
and heated, the lactic acid is decomposed into 
acetic aldehyde and formic acid, according to the 
equation 



CH, 



CHOH)— CO.OH 

Lactic acid. 



= CH3.CHO + H.CO.OH. 
Acetic aldehyde. Formic acid. 



Practically, then, the test for lactic acid resolves 

• x ii» • . l j? x- liii i-i Strauss' apparatus for 

ltseli into a test tor acetic aklehvde, which can the approximative 
readily be recognized by testing with various re- ^ d mation of lactic 
agents, such as an alkaline solution of iodo-potassic 
iodide, Xessler's reagent, and others. Nessler's reagent is prepared 
as follows : 2 grammes of potassium iodide are dissolved in 50 c.c. 
of water and treated with mercuric iodide while heating, until some 
of the latter remains undissolved. Upon cooling, the solution is 
diluted with 20 c.c. of water. Two parts of this solution are then 
treated with 3 parts of a concentrated solution of potassium hydrate ; 
any precipitate that may have formed is filtered off, and the reagent 
kept in a well-stoppered bottle. When aldehyde is added to such a 
solution a yellowish-red or red precipitate results, the exact color 
depending upon the amount of aldehyde present. One part of the 

1 Boas, Deutsch. med. Woch., 1893, No. 39; and Munch, med. Woch., 1893, No. 43. 



188 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

aldehyde may still be recognized when diluted with 40,000 parts of 
water. 

With an alkaline solution of iodo-potassic iodide, aldehyde in a 
dilution of 1 : 20,000 will still produce a cloudiness, referable to the 
formation of iodoform, which is readily recognized by its character- 
istic odor (Lieben's test for acetone). 

Method. — The filtered gastric juice is tested for the presence of 
free acids with Congo-red (see page 163). If present, from 10 to 20 
c.c. are evaporated to a syrup on a water-bath, after the addition of 
an excess of barium carbonate, while the latter is unnecessary in the 
absence of free acids. The syrup is treated with a few drops of 
phosphoric acid, and the carbon dioxide removed by bringing it to 
the boiling-point once only, when it is allowed to cool and extracted 
with 100 c.c. of neutral sulphuric ether (free from alcohol), by shaking 
for half an hour. The layer of ether is poured off after half an hour, 
the ether is evaporated (no flame), the residue taken up with 45 c.c. of 
water, shaken and filtered, and finally treated with 5 c.c. of sulphuric 
acid and a pinch of manganese dioxide in an Erlenmeyer flask. 
This is closed with a perforated stopper carrying a glass tube bent 
at an obtuse angle, the longer limb of which passes into a narrow 
glass cylinder containing from 5 to 10 c.c. of Nessler's reagent or a 
like quantity of an alkaline solution of iodo-potassic iodide. If heat 
is now carefully applied, the aldehyde, formed by the oxidation of 
the lactic acid with manganese dioxide and sulphuric acid, passes 
over when the boiling-point is reached, and causes the precipitation 
of yellowish-red aldehyde of mercury in the tube containing the 
Nessler's reagent, or of iodoform if the alkaline solution of iodine 
is employed. 

Quantitative Estimation of Lactic Acid according to Boas' 
Method. 1 — The principle already set forth also applies to the quanti- 
tative estimation of lactic acid. 

Solutions required : 

1. A one-tenth normal solution of iodine. 

2. A one-tenth normal solution of sodium thiosulphate. 

3. Hydrochloric acid (sp. gr. 1.018). 

4. A potassium hydrate solution (56 : 1000). 

5. Starch solution. 
Preparation of these solutions : 

1. A normal solution of iodine should contain 126.53 (molecular 
weight of iodine) grammes of iodine in the liter, and a one-tenth 
normal solution, hence 12.6 grammes. In order to dissolve the 
iodine 25 grammes of potassium iodide are dissolved in about 200 
c.c. of distilled water, when the 12.6 grammes of resublimed iodine 
are added. This solution is then diluted with distilled water to the 
1000 c.c. mark, and requires no further correction. 

Loc. cit., p. 187. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 189 

2. The one-tenth normal solution of sodium thiosulphate is pre- 
pared as described in the chapter on Acetone (sec Urine). When 
treated with 1 gramme of ammonium carbonate pro liter it will 
retain its titre almost indefinitely. 

3. Preparation of the starch solution : 5 grammes of starch are 
dissolved in 1)00 c.c. of water by heating, when 10 grammes of zinc 
chloride in 100 c.c. of water are added. 

METHOD. — Ten to 20 c.c. of the filtered gastric juice are first 
treated as indicated above, viz., evaporated to a syrup after the 
addition of barium carbonate if free acids are present. A few- 
drops of phosphoric acid are added, the carbon dioxide driven off 
by boiling, and the residue extracted, on cooling, with 100 c.c. of 
ether free from alcohol ; the ether is evaporated after separation, 
the residue taken up with 45 c.c. of distilled water, and treated 
with manganese dioxide and sulphuric acid. The flask is closed by 
a doubly perforated stopper ; through one aperture a bent tube passes 
to the distilling-apparatus, and a straight tube provided with a piece 
of rubber tubing, clamped off, through the other. The latter should 
dip well down into the liquid, and serves for passing a current of air 
through the solution when the distillation is completed. The mixt- 
ure is distilled until about four-fifths of the contents have passed 
over, excessive heat being carefully avoided, as otherwise the aldehyde 
will be decomposed, according to the equations : 

(1) CH 3 - CH(OH) - CO.OH = CH..CHO + HCOOH. 

Lactic acid. Aldehyde. Formic acid. 

(2) CH :{ .CHO + HCOOH + 20 = CH 3 .COOH 4- C0 2 + H 2 0. 
Aldehyde. Formic acid. Acetic acid. 

To the distillate, which is best received in a high Erlenmever 
ftask, well stoppered, 20 c.c. of the one-tenth normal solution of 
iodine are added, mixed with 20 c.c. of the 5.6 per cent, solution of 
potassium hydrate. The mixture is shaken thoroughly and allowed 
to stand for a few minutes. In order to liberate the iodine not \\<cd 
in the reaction, 20 c.c. of hydrochloric acid are added, and the ex- 
cess of iodine determined by titration with the one-tenth normal solu- 
tion of sodium thiosulphate. The titration is carried almost to the 
point of decolorization, when a little starch solution is added ; the 
mixture is then titrated until the blue color has disappeared. The 
number of cubic centimeters of the one-tenth normal solution em- 
ployed, viz., 20, minus the number of cubic centimeters of the one- 
tenth normal solution of sodium thiosulphate, will then indicate the 
number of cubic centimeters of the former required for the formation 
of iodoform, viz., the amount of lactic acid present in 10 or 20 c.c. 
of gastric juice, as the case may be. As 1 c.c. of the one-tenth 
normal solution of iodine has been found to indicate the presence of 



190 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

0.003388 gramme of lactic acid, it is only nec»r— : : multiply the 
number of cubic centimeters used by this figure, and the resul: 
1 in order to obtain the percentage. 

The method described is reliable and sufficiently accurate for clini- 
cal purposes. At the same time it may be said that no more time 
is : quired than in the ordinary quantitative estimation of sugar by 
means of Tehling's method, or of hydrochloric acid according to 
the method of Martins and Luttke. 

L ..-_-' Pt.-_?'H Mz~h-:c-. — This ni-r::- 1 is ir— ■;, ;■.;■-.-.:- u:t :!:::.:". the 
preceding one 5 but may be advantageously employed in the absence 
of the various reagents necessary with the former. Ten c.c. of 
filtered gastric juice are treated with a tew drops of dilute sulphuric 
acid, and the albumin present removed by heat. The nitrate is evapo- 
rated to a svrup on a water-bath, water added to the original 
amount, and this again evaporated to a small volume, fatty acids 
being thereby removed. The lactic acid reinaining is now extracted 
with ether (200 :. : every 10 c.c. of gastric juice) ; the ether is 
evaporated, the residue taken up with water and titrated with a 
one-tenth normal solution of sodium hydrate, using phenolphthalein 
as an indicator. As 40 parts by weight of sodium hydrate (molecu- 
lar weight) combine with 90 parts by weight of lactic acid (molecu- 
lar weight), and as 1 c.c. of the one-tenth normal solution of 
sodium hydrate contains 4 irramme of sodium hydrate, the 

corresponding amount of lactic acid is found from the equation : 
40:90: : 0.004: x; 4t = 0.360 ; x = 0.009. The value of 1 
of the one-tenth normal solution in terms of lactic acid is thus 0.009. 
By multiplying the number of cubic centimeters used by this figure, 
the amount of lactic acid present in 10 c.c. of gastric juice is 
- rtained. The result multiplied by 10 indicates the percentage. 

The Fatty Acids. 

Mode of Formation and Clinical Significance. — Unless ir.uoh 
milk or carbohydrates have been ingested, fatty acids do not occur 
in the gastric contents under physiological conditions, and it would 
appear from the researches of Boas * that their formation is intimately 
ss iated with that of lactic acid. Alter the exhibition of his fce afc- 
meal (see page 150) he was unable to demonstrate their presence 
either in health or in varions diseases of the stomach, such as chronic 
_ - itas atony or dilatation referable to benign canses, etc. In 
carcinoma^ however, fatty acids, just as lactic acid, were quite 
stantly found. 

That butyric acid can be derived from lactic acid has been demon- 
strated by Flugge. the reaction taking place according to the equation 

2C,H € Q 3 = H : Hh4H 

1 Loc. cit. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 191 

This observation is probably explained by the fact that mosl of the 
organisms causing butyric acid fermentation arc anaerobic, while the 
Bacillus acidi lactici and the Oidium lactis eagerly absorb oxygen. 

Acetic acid fermentation, on the other hand, presupposes the pres- 
ence of alcohol, whether this is introduced into the stomach as such 
or whether it results from the action of yeast (Saccharomyces cere- 
visise) upon sugar. The transformation of alcohol into acetic acid 
is represented by the equation 

C 2 H 5 OH + 20 = C 2 H 4 2 + H 2 0, 

while the formation of alcohol during the process of fermentation 
from glucose is shown below : 

(\\l v p, 2H 2 = 2C 2 H 6 + 2II 2 + 2C0 2 . 

It is, hence, necessary, whenever acetic acid is met with in the 
gastric contents, to exclude the presence of alcohol, as only then 
is it permissible to refer its presence to stagnation and advanced 
decomposition of carbohydrates. 

If the examination is confined to an analysis of the gastric 
contents obtained otherwise than after the exhibition of Boas' or 
Ewald's test-meal, the diagnosis of pyloric stenosis with dilatation 
i- probably always justifiable in the presence of notable quantities 
of butyric acid and acetic acid, while the same after a previous 
washing-out of the stomach and the exhibition of Boas' test-meal 
would surest carcinoma as the cause of the stenosis. 

That butyric acid may occur in the gastric contents when butter 
or fats in general have been ingested is, of course, not surprising, 
and its presence then should be looked upon as a physiological occur- 
rence. At the same time it should not be forgotten that butyric acid, 
just as lactic acid, may possibly have been formed in the mouth, and 
conclusions should, hence, only be drawn when such sources of error 
can be definitely excluded, and the amount found exceeds mere traces. 

In conclusion, it may be said that in disease butyric acid is far 
more frequently encountered in the gastric contents than acetic acid, 
but the significance of the two, if alcoholism can be excluded, is the 
same. 

Tests for Butyric Acid. — 1. Butyric acid can usually be recog- 
nized by its odor alone, which is that of rancid butter. Often, how- 
ever, it will be necessary to resort to more definite tests, such as the 
following : 

2. Ten c.c. of filtered gastric juice are extracted with 50 cc. of 
ether. The ether is evaporated and the residue taken up with a few 
cubic centimeters of water. If a trace of calcium chloride in sub- 
stance is now added, the butyric acid will separate out in the form of 
oil-droplets, the nature of which is readily recognized by the pungent 



192 THE GASTRIC JUICE AXD GASTRIC CONTENTS. 

odor. If, instead of adding calcium chloride, a slight excess of 
baryta-water is used, strongly retractive rhombic plates or granular, 
wart-like masses of barium butyrate are obtained upon evaporation. 

3. Butyric acid may also be recognized by the peculiar odor of 
pineapple which develops when the dry residue of the ethereal 
solution is treated with a little sulphuric acid and alcohol. The 
reaction is due to the formation of butyl ethylate (Pineapple test). 

Tests for Acetic Acid. — 1. Like butyric acid, acetic acid can 
usually be recognized by its odor. 

2. Ten c.c. of filtered gastric juice are extracted with ether. The 
ether is evaporated, the residue dissolved in a few drops of water, 
and accurately neutralized with a dilute solution of sodium hydrate, 
sodium acetate being formed. If to this a drop or two of a very 
dilute solution of ferric chloride is added, a dark-red color results 
in the presence of acetic acid. With silver nitrate a precipitate is 
obtained which is soluble in hot water. 

Quantitative Estimation of the Fatty Acids. — Method of Cahn- 
Mehring, modified by McNaught. 1 — The total acidity is determined in 
10 c.c. of filtered gastric juice. ADother 10 c.c. are evaporated 
to a syrup, diluted with water, and similarly titrated. The difference 
between the two results will indicate the amount of fatty acids 
present. 

Quantitative Estimation of the Organic Acids. — Method of 
Hehner-Seemaim. 2 — This method is based upon the observation that 
if a certain amount of a one-tenth normal solution of sodium 
hydrate is added to organic acids and the mixture is evaporated and 
incinerated, the organic acids are decomposed, with the liberation of 
carbon dioxide, while their alkali is left behind in the form of a 
carbonate ; this is then determined by titration with a one-tenth 
normal solution of hydrochloric acid. The amount of physiologi- 
cally active hydrochloric acid can be estimated at the same time by 
deducting from the total acidify the acidity referable to organic acids. 

Method. — Ten or 20 c.c. of filtered gastric juice are titrated with 
a one-tenth normal solution of sodium hydrate, evaporated to dry- 
ness, and incinerated, the application of heat being discontinued as 
soon as the ash has ceased to burn with a luminous flame. The 
residue is taken up with water and titrated with a one-tenth normal 
solution of hydrochloric acid. This is prepared by dilating 146 
grammes of the concentrated acid (sp. gr. 1.14) with distilled water 
to about 900 c.c. when the solution is brought to the proper strength 
by comparing it with a one-tenth normal solution of sodium hydrate, 
according to directions given elsewhere. The number of cubic cen- 
timeters of the one-tenth normal solution of hydrochloric acid 

1 Cited by Boas. Diagno>tik n. Thempie d. Ma.senkrankheiten. 2d ed., 1891, p. 140. 

2 Seemann, " Ueber d. Vorhaudensein freier Salzsiiure im Masen."* Zeit. f. klin. 
Med., vol. v. p. -27-2. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 193 

employed multiplied by 0.00365 will indicate the amount of fatty 
acids in the 10 c.c. of gastric juice, in terms of hydrochloric acid ; 
the percentage is ascertained by multiplying by 10 or 5, as the case 
may be. By deducting the number of cubic centimeters employed 
from that of the one-tenth normal solution of sodium hydrate, first 
used, the number of cubic centimeters of the latter required for the 
neutralization of the physiologically active hydrochloric acid is 
ascertained, and the amount determined by multiplying by 0.00365. 

Gases. 

The stomach always contains a certain quantity of gases which 
have partly been swallowed and partly have passed into the stomach 
from the duodenum. As fermentative processes in health occur only 
when carbohydrates or fats have been ingested, and then only to a 
slight degree, nitrogen, oxygen, and carbon dioxide are the only 
gases found during the process of albuminous digestion. As the 
oxygen swallowed is, moreover, largely absorbed by the blood, and 
two volumes of carbon dioxide are returned for one volume of oxy- 
gen, the presence of large amounts of the former and small amounts 
of the latter is readily explained. In an analysis of the gases con- 
tained in the stomach of a dog which had been fed en meat, Planer 
found the following proportions : 

Carbon dioxide 25.2 vol. per cent. 

Oxvgen 6.1 " " 

Nitrogen 68.7 " " 

With a strict vegetable diet, on the other hand, hydrogen may 
also be found (Planer) : 

Man. Dog. 

Carbon dioxide .... 20.79 33.83 32.9 vol. per cent. 

Oxvgen 0.37 0.8 " " 

Nitrogen 72.50 38.22 66.3 " " 

Hydrogen 6.71 27.58 

The presence of hydrogen is readily understood, if it is remembered 
that during the process of butyric acid fermentation hydrogen and 
carbon dioxide are formed. Lactic acid or acetic acid fermentation 
does not give rise to the formation of gases. 

Marsh gas, CH 4 , a product of the fermentation of cellulose, may 
also be found in pathological conditions, and is formed according to 
the equation 

(Q*H 10 O 6 ) n iIT,0) H = 3(C0 2 ) rt + 3(CII,)„ 

It is yet an open question whether marsh gas is formed in the 
stomach or passes into the stomach from the small intestine. 

13 



194 THE GASTRIC JUICE ASL 1ASTRIC CONTENTS. 

Such observations must, however, be regarded as rarities. In 

one case of this kind, examined by Ewald and Ruppstein. 1 in which 

hoi, acetic acid. 1; ::: "I. and butyric acid were found in the 

vomited material, an analysis : :_r gases gave the following result : 

Carbon dlixLii 20.6 vol. per eent 

Oxvs:en ' 

Nitrogen 41.4 H 

Hvdrosen 20.1 " 

:: » r - 10,8 

Traces of defiant gas and of hydrogen sulphide were also found. 
It is curious to note that in this case the patient, who. according - 
his :wn statement, ha id i u vinegar-factory in his stomach on >ne 
day and gas-works on another day." was occasionally able to light 
the erncfe bed g - at the end of a cigar-holder, where it burnt with 
a faintly luminous flame. MeNaught has reported a similar ease, 
in which the analysis furnished the following results : carbon 
dioxide, oft per cent.: hydrogen. 28 per cent.: marsh gas, 1.8 per 
cent.; atmospheric air. 9.2 per cent.- 

Ammonia and hydrogen sulphide are also at times met with : 
their presence is always : albuminous putrefaction. 

I is found that hydrogen sulphide is quite commonly present 
in cases of dilatation referable to benign causes, while it is almost 
always absent in carcinoma. He adds that it is never found when 
lact: I is present. In acute gastritis it may be observed tem- 

porarily. In a number of cases of carcinoma I have never found 
hydrogen sulphide. In one case reported by Strauss the Bacillus 
eoli communis was apparently concerned in its production. 

obtain a know] _ f the gs ses : lined in the stomach during 
the process : digestion it is only necessary to rill an ordinary 
Doremns ureorneter. or an Einhorn saccharimeter. with the unfil: 
gastric contents, and to keep it at a tempera tirre of from 37 c to 
when the evolution : gas an be followed closely and the 
nc ssary tests m I . The presence of carbon dioxide is readily 
gnized by passing a small amount of sodium hydrate, in concen- 
trated solution or in substance, into the tube, after the evolution has 
entirely - -hen the fluid will rise Z: thet gases are present 
time, they will remain after the carbon : :: has 

- rbed. Hydi _ - is -."idily recognized by its odor 
and by the fact that it will color a piece of filter-paper, moistened 

m 

'- Kc': " . . ' \-g brennb-v i - — in memsehliehen 

- ■ . .: . : and De W h 189@ K -.:■. and 

'Bom - -" - ilduns in Mas-enkrankheiten." Centralbl. f. 

inn. H ' " - " '.' - ■ • • ~ |g . r « ;; - -■ - &j - ■ - 

w -- •-" _ ball)], f. in- " . Dauber, 

L Verdi zski '■: - . :~ | 1 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 195 

with a few drops of sodium hydrate and lead acetate a more or less 
pronounced brown or black. The test is conveniently made by 
filling a test-tube about half-full with the gastric contents and clos- 
ing it with a cork stopper to which a strip of lead-paper, prepared 
as indicated, is fastened. 

The eructation of pis formed in the stomach should not be con- 
founded with the so-called eruetatio nervosa, in which no gas is either 
eructated, or air simply enters the oesophagus and is expelled again 
with a loud, explosive noise. This may frequently be observed in 
neurasthenic and hysterical individuals, and is to a greater or less 
degree under the control of the will. It is hardly likely, however, 
that the physician will be called upon in the laboratory to differen- 
tiate between this form and that of true ructus, caused by fermenta- 
tive processes taking place in the stomach. The gases brought up 
in the former condition are without odor or taste, and thus differ 
from those found in true dyspepsia. 

Acetone. 

The presence of acetone in the gastric contents in pathological 
conditions has repeatedly been observed, especially by v. Jaksch and 
Lorenz, 1 and it is curious to note that the latter was at times able to 
demonstrate larger quantities of the substance in the gastric con- 
tents than in the urine. 

In the chapter on Acetonuria the relation existing between diges- 
tive diseases and the elimination of acetone will be dealt with more 
fully, but it may here be mentioned that in the primary diseases of 
the gastro-intestinal tract acetone is met with quite constantly in 
the gastric contents, while it is observed but rarely in the secondary 
forms, and never is seen in the gastric neuroses. This statement, 
however, is denied by Sovelieff, who claims to have found traces of 
acetone in only one case of nervous dyspepsia, while negative results 
were obtained in all other diseases of the stomach. I have re- 
peatedly been able to demonstrate the presence of acetone in cases 
of carcinoma, and never have found it in neurotic conditions. 

In order to test for acetone, the gastric contents are distilled after 
the previous addition of a small amount of phosphoric acid (1 : 
1000), when the tests of Reynolds and Gunning (see Urine) are 
applied to the distillate. If both reactions furnish a positive result, 
the presence of acetone may be regarded as demonstrated. Den- 
niges' test may also be employed, and can be applied to the filtered 
contents directly (see Urine). 

Ptoma'ins and Toxalbumins. 

Remembering that ptomaine and toxalbumins have been obtained 
directly from tainted meat, sausage, fish, clams, crabs, cheese, etc., it 

lorenz, Zeit. f. klin. Med., 1891, vol. xix. p. 19. 



196 



THE GASTRIC JUICE AND GASTRIC CONTENTS. 



is to be expected that these bodies may be met with in the gastric 
contents also. At the same time it may be mentioned that the 
stomach appears to possess the power of eliminating from the system 
poisons of this nature which are circulating in the blood. This is 
shown by the observations of Alt, who found that the water with 
which the stomach of an animal had been irrigated, after the sub- 
cutaneous injection of the poison of Pelias berus and Echidna 
arictans, or the direct bite of the snake, produced identical symp- 
toms of poisoning when injected into another animal. It is inter- 
esting to note that with lavage of the stomach the poisoued animal 
recovered. Similar observations have been made in cholera Asiatica. 
Certain vegetable alkaloids, such as morphin, are also known to be 
eliminated to a large extent by the stomach. Of the nature of the 
ptomains and toxalbumins which may occur in the stomach, very 
little is known. 1 



Vomited Material. 

Food-material. — The vomiting of large amounts of totally undi- 
gested meat two or three hours after its ingestion is met with only 
in conditions associated with an entire absence of digestive juices 

Fig. 38. 




Collective view of vomited matter. (Eye-piece III., objective 8 A, Reiehert.) a, muscle- 
fibres ; b, white blood-corpuscles ; c, c', squamous epithelium; c'', columnar epithelium; d, 
starch-grains, mostly changed by the action of the digestive juices ; e, fat-globules ;/, sarcinse 
ventriculi ; g, yeast-fungi ; h, forms resembling the comma-bacillus found by the author once 
in the vomit of intestinal obstruction ; i, various micro-organisms, such as bacilli and micro- 
cocci ; k, fat-needles, between them connective-tissue derived from the food ; I, vegetable 
cells, (v. Jaksch.) 

from the stomach — i. e., in cases of atrophic cirrhosis of the stomach 
(anadeny of Ewald). This condition is not to be confounded with 

1 Brieger, Untersuchungen iiber Ptomaine, Hirschwald, Berlin, 1886. 



CHEMICAL EXAMINATION OF THE GASTRIC JUICE. 197 

the regurgitation of undigested food, mixed with mucus and saliva, 
which is seen in cases of stricture of the oesophagus or of the car- 
diac orifice of the stomach. While at the outset of the latter 
disease the regurgitation of food occurs immediately, or at least 
very soon, after a meal, it may take place between meals in the 
later stages of the disease when dilatation has occurred. The 
recognition of the origin of the material brought up may then 
be exceedingly difficult. In such cases an examination should be 
made for biliary coloring-matter, which, if present, will, of course, 
immediately exclude the oesophagus as the source of the material 
ejected. Unfortunately, however, the reverse does not hold good. 
Small amounts of undigested meat are of no significance. The 
vomiting of well-digested food is observed in some of the neuroses 
of the stomach, and also in certain cases of acute and subacute gas- 
tritis, ulcer of the stomach, and chronic gastritis in its early stages. 
The vomiting referable to cerebral and spinal diseases also belongs 
to this category. In this connection it is very important to inquire 
into the existence of nausea previous to the vomiting, for, as is well 
known, considerable amounts of saliva and mucus may be swal- 
lowed if much nausea has existed, the result being that the process 
of digestion is arrested before the occurrence of vomiting. In such 
an event it would be erroneous to conclude that, because the mate- 
rial ingested has not reached that stage of digestion which would be 
expected at the time of the vomiting, the stomach is incapable of 
properly performing its functions. 

Mucus. — The constant presence of large amounts of mucus in 
the gastric contents obtained with the stomach-tube is almost 
pathognomonic of the mucous form of gastritis, while its presence in 
vomited matter may be referable to pre-existing nausea. In cases of 
pharyngitis moderate amounts of mucus are frequently found. The 
vomiting of pure mucus, according to Boas, is always pathognomonic 
of the absence of dilatation of the stomach, a statement founded on 
reason, as it is altogether unlikely that no particles of food should 
be brought up at the same time. 

Under the term gastrosuecorrhoea mucosa Dauber l has described 
a condition in which large amounts of mucus are secreted by the 
non-digesting organ, in the absence of symptoms pointing to a 
gastritis. I have observed a similar case occurring in a neuras- 
thenic patient, in which enormous quantities of mucus could at times 
be obtained from the fasting organ, but never during the process of 
digestion. A mild degree of hyperchlorhydria existed at the same 
time, as well as enteritis mucosa and rhinitis mucosa. The motor 
power was practically normal. 

Mucus is readily recognized on simple inspection by its glossy 

1 Dauber, " Ueber kontinuirliche Magen-Scbleirnsecretioii," Arcb. f. Verdauungs- 
krank., vol. ii. p. 1G7. 



198 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

appearance. Chemically, it is distinguished by its behavior toward 
acetic acid (see Urine). 

Saliva. — The vomiting of pure saliva in the morning upon rising 
is a fairly common symptom of chronic pharyngitis, which in turn 
frequently carries in its train a chronic gastritis ; it constitutes the 
so-called vomitus matutinus. Saliva, like mucus, is, of course, 
always present in the gastric contents in small amounts. Larger 
amounts are usually referable to an increased secretion owing to the 
existence of nausea. Chemically, saliva is best recognized by test- 
ing for the presence of the sulphocyanides (see Saliva, page 138). 

Bile. — Bile is rarely observed in the gastric contents brought up 
by the stomach-tube, but is frequently seen in vomited matter, of 
which it may be said to be a constant constituent whenever the 
vomiting has been very intense or frequently repeated. Its presence 
in the former case should always excite suspicion of the existence of 
stenosis of the descending or horizontal portion of the duodenum or 
the beginning of the jejunum. This diagnosis becomes the more 
probable the more constant its presence. 

Pancreatic Juice. — Mixed with the bile there is probably always 
present some pancreatic juice, and it has even been suggested that 
the constant absence of this constituent, in the presence of bile, is 
strongly suggestive of pancreatic disease or of obstruction of the 
pancreatic duct (the ductus Wirsungianus). 

Blood. — The presence of unaltered blood in the gastric contents 
is usually recognized without difficulty. As marked changes in 
color, varying from a deep red to a coffee or chocolate brown, may 
occur, however, when free acids are present, it is at times necessary 
to resort to a more detailed examination. In order to recognize mere 
traces when the macroscopical and even the microscopical examination 
do not point to the presence of blood, the method of Miiller and 
Weber or that of Donogany should be employed. Kuttner claims 
that he was thus able to demonstrate the presence of blood in nu- 
merous cases of chlorosis in which other tests furnished negative 
results. I have been less successful in the disease in question, but 
admit that in cases of carcinoma and ulcer of the stomach it is with 
this method often possible to find traces of blood which would other- 
wise have remained unnoticed. 

Method of Miiller and Weber. — The gastric contents are treated 
with a few cubic centimeters of strong acetic acid and extracted with 
ether. Should the ether not separate in a clear layer after a few 
minutes, a few drops of alcohol are added. If the ether then 
remains colorless, no blood-pigment is present, while a brownish- 
red color indicates the presence of acetate of haBmatin. As a similar 
but yellowish-brown and much less intense discoloration of the 
ether may be produced by other pigments, such as biliary coloring- 
matter, it is well, in doubtful cases, to test the ethereal extract with 






GHEMWAL EXAMINATION OF THE GASTRIC JUICE. 199 

tincture of guaiacum. A positive result indicates the presence of 
blood coloring-matter. The same may be said it", upon spectroscopic 

examination of the ethereal extract, an absorption-band is discov- 
ered at the junction of the red and yellow. 

Donogany's Method. — A small amount of the suspected material 
is extracted with a 20 per cent, solution of sodium hydrate and 
filtered. A drop of the filtrate is then mixed on a slide with a drop 
of pyridin and covered with a cover-glass, when, in the presence of 
blood, orange-red crystals of hsemochromogen will separate out on 
standing for a few hours. On spectroscopic examination these 
crystals will show the characteristic band of absorption between the 
yellow and the green. 

Hemorrhage from the stomach, hcrmatejuesis, may be observed in 
the most diverse conditions. It is either dependent upon a primary 
disease of the organ, such as ulcer and carcinoma, or it occurs sec- 
ondarily to disease of other organs, leading to a hypersemic condi- 
tion of the gastric mucosa, such as the various forms of cardiac, 
renal, and hepatic disease, in connection with menstrual abnormali- 
ties, etc. In melsena, purpura hemorrhagica, pernicious anaemia, 
etc., the cause of the hemorrhage cannot always be determined. It 
appears to be certain, however, that nervous influences may also take 
part in the causation of gastric hemorrhage. 

Pus. — The occurrence of pus in vomited matter, referable to 
disease of the stomach itself, is uncommon. It is seen practically 
only in cases of phlegmonous and diphtheritic gastritis, and, as 
Strauss l has pointed out, in carcinoma affecting the smaller curva- 
ture and the region of the fundus. In such cases it is not uncom- 
mon to obtain as much as one-half to two tablespoonfuls of a 
mucopurulent fluid from the non-digesting organ. As the motor 
function in this form of carcinoma is often unimpaired, the symptom 
may be of considerable value in diagnosis. The presence of larger 
quantities usually indicates perforation into the stomach of an 
accumulation of pus from a neighboring organ. An abscess of the 
liver, a suppurative pancreatitis, an abscess of the colon, or a sub- 
phrenic abscess may thus prove to be its primary source. When 
present in considerable amount pus is, of course, readily detected 
with the naked eye ; if any doubt should arise, a microscopical 
examination will determine the question. 

Stercoraceous Material. — Very important from a clinical stand- 
point is the vomiting of stercoraceous matter which is notably 
observed in cases of ileus. Usually this is recognized without diffi- 
culty by its odor, which is referable to the presence of skatol. If 
any doubt should arise, it is only necessary to distil the vomited 
matter after the addition of a little phosphoric acid, and to test 
for the presence of phenol, indol, and skatol in the distillate, as 

1 H. Strauss, " Ueber Eiter im Magen," Berlin, klin. Woch., 1899, p. 870. 



200 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

described in the chapter on Feces (see page 216). ^YTien chiefly 
derived from the small intestine, the vomited matter, according to 
v. Jaksch. will contain bile-acids and bile-pigment together with an 
abundance of fat. which may be detected by chemical or microscop- 
ical examination. The reaction is usually alkaline or feebly acid. 

I have had occasion to examine the vomited matter of a patient 
in whom an almost complete obstruction existed immediately above 
the ileo-ctecal valve ; the color of the material was a golden yellow, 
the reaction neutral : no bile-pigment or biliary acids were found, 
while hydrobilirubin was present. 

Parasites. — Of parasite-, ascarides. segments of tamia?. trichina?, 
Anchylostoma duodenale, and Oxyuris vermicularis are, at times, 
encountered. The Trichomonas vaginalis has also been seen in one 
case of carcinoma of the oesophagus. 1 For a description of these 
parasites see the chapter on the Feces. 

The Odor. — The odor of normal gastric juice is peculiar, 
suggesting the presence of some acid, which can be sharply dis- 
tinguished from the odor referable to acetic acid or butyric acid. 
If blood is present in large amount, the vomited matter emits an 
odor which is so characteristic as never to be mistaken. A feculent 
odor is met with in cases of enterostenosis or in the presence of an 
abnormal communication between the stomach and the small or 
large intestine. A putrid odor may* be observed in cases of ulcera- 
tive carcinoma, pyloric stenosis referable to ulcer, simple carcinoma 
of the stomach, muscular hypertrophy of the pylorus, stenosis due 
to inflammatory adhesions, etc. In cases of phosphorus poisoning 
the vomited matter emits an odor of garlic : the odor observed in 
ura?inic conditions is referable to ammonia : a carbolic acid odor is 
met with in cases of poisoning with this substance. 

MICROSCOPICAL EXAMINATION OF THE GASTRIC 
CONTENTS. 

In the gastric juice obtained from the non-digesting stomach the 
various morphological constituents of mucus and saliva, which have 
been described elsewhere, are found. Microscopical particles of 
food, such as elastic tissue-fibres, starch-granules, fat-droplets, fatty 
acid crystals, vegetable- and muscle-fibres, are. furthermore, quite 
constantly seen. Leucocytes and isolated nuclei also are observed ; 
the latter are set free by the action of the gastric juice upon the 
muc«>us corpuscles and epithelial cells. 

If gastric juice is allowed to stand, small tapioca-like bodies will 
collect at the bottom of the vessel, which upon microscopical exami- 
nation will be seen to contain numerous suail-shell-like formations, 

1 G. ^Triibe. *" Trichomonas koniinis bei Carcinoma venrriculi."" Berlin, klin. Woch., 
1898,] 708 



PLATE X 














The Boas-Oppler Bacillus, Stained with Methylene Blue. From a Case 
of Carcinoma of the Large Curvature of the Stomach. 
Personal Observatio 



MICROSCOPICAL EXAMINATION OF GASTRIC CONTENTS. 201 

occurring either singly or collected in groups. Those probably con- 
sist of altered mucin, as they can be produced artificially by adding 
a sufficient amount of dilute hydrochloric acid to saliva. Accord- 
ing to Boas, they arc of no diagnostic significance. 

Epithelial cells, fragments of the epithelial lining of the ducts of 
glands, as well as goblet-cells, are not infrequently met with in the 
juice obtained from the non-digesting organ. In addition, various 
micro-organisms, such as the Leptothrix buccalis, Bacillus subtil is, 
saccharomyces, micrococci (often arranged in the form of tetrahedra), 
Clostridium butvricum, etc., may be encountered. 

Among the bacteria which may be found in the gastric contents 
under pathological conditions the bacillus described by Boas and 
Oppler l is undoubtedly the most important, and has of late attracted 
much attention. It appears to be present quite constantly in car- 
cinoma, and is almost always absent in other diseases of the stom- 
ach. It is thought that the formation of lactic acid, which is like- 
wise so constantly observed in carcinoma, is largely and perhaps 
solely referable to its presence. The organism in question (Plate 
XI.) is non-motile, and essentially characterized by its great length 
and by the fact that the individual bacilli are frequently seen joined 
end to end, forming long threads and zigzag lines w r hich are very 
characteristic. Often the entire field of vision is filled with dense 
conglomerations. Cultivation-experiments have thus far not been suc- 
cessful. The organism is readily stained with the usual anilin dyes. 

Tubercle bacilli may be found in vomited matter in cases of 
phthisis, where the sputa have been swallowed. Tubercular ulcera- 
tion of the stomach is exceedingly rare. Simmonds reports that 
in 2000 autopsies of tubercular individuals the condition was noted 
only eight times. 

San- 1 ,ue (Fig. 38) occur in the form of peculiar colonies of cocci, 
arranged in squares or tetrahedra, strongly resembling cotton-bales. 
Not infrequently they are encountered under normal conditions, but 
only in small numbers. In pathological conditions, on the other 
hand, a drop of the gastric contents may constitute an almost pure 
culture. A case is even on record in which the pylorus had become 
entirely occluded by an inspissated mass of these organisms. When- 
ever present the existence of certain fermentative processes may 
be inferred. 

It is curious to note that in advanced cases of carcinoma of the 
stomach sarcinse are practically never seen, although the conditions 
arc apparently most favorable for their development. Oppler 2 was 
unable to find them twenty-four hours after their introduction in 

1 Oppler-Boas. " Zur Kenntniss des Mageninhalts bei Carcinoma ventrienli," 
Deutsch. med. Woch., 1895, No. 5. Kiiuffmanii, " Ueber einen neuen Milchsaure- 
bacillus," etc.. Wien. klin. Woch., 1895, No. 8. Schlesinger u. Kauffmann, Wien. klin. 
Kundschau. 1895, No. 15. 

2 Oppler, Munch, med. Woch., 1894, No. 29. 



THE GASTRIC JUICE AXD GASTRIC COWTEWT& 

large numbers and in pome colters. In caeeg of carcinoma of the 
eurvatares and the nails, as also in advanced pyloric carcinoma, 
sareinge were never found, while their may he present in incipient 
cases of pyloric carcinoma so long as hydrochloric acid is secreted. 

In vomited material containing biliary coloring-matter, lencin ? 
:;:-:_ ;,:: ... — : in . :- r.r : ~~^~ \zlj ' -:'-\ zzzi z:.:.~ '.- 
recognized by the form of their crystals, as well as by their chem- 
ical reactions, which are described elsewhere. 

The occurrence of blood and pus in the gastric contents has been 
;• z.-ii-z-ni — - ■ , ^— 1 . : v . ■_ .". 1 ■ " 

x: z : :.:_:_: :_rz:.- _. " " -: - :_ . : -::... _ -_:r.- : z: '.:. : > zz~zz- 
brane are brought away by the stomach-tube, and in cases of chronic 
sastritas, hvi'-: ; hi i jivdria not dependent npon nicer, and in some 
of the neuroses, this is indeed not at all uncommon. 11 ' Boas even 

ggests that in the neuroses, where fragments of mucous membrane 

- : :.- - _. iLi: — ~ ; — : .7 zzz- ~- . -:: _ z. ij 

with the formation of ulcers, and there can be no doubt thai the 

mere action of the abdominal muscles exerted during the process 

of defecation may be sufficient to detach such fragments. From 

7i- :': 








■ v ■- " •■'•■." :'• i_ ' ■ .- ■• : ' 7' ' '_'■-:..'• fv ^i 



the mieroseopical appearance of the particles the diagnosis between a 
gastric neurosis and one of the various forms of chronic gastritis 
may frequently be made, and the same may be said to hold good in 

:": ■ t "~ -' . - _ -:- •-- — z : rrz-. _" "-t:-.-:- :z~ . j.:z..z:~ 
insufficiency referable to passive congestion of the gastric mucosa. 



11 JUL fimhom, MeA. BmradL Jan 

f. TqdbuBiBiBgiifcTTaaBfcBneiitem, wwL v. Heffit 3. 



kffim_ WaA^lSBS,, 5T«l 39; Jkidk. 



EXAMINATION OF THE MOTOR POWER OF THE STOMACH. 203 

At times tumor particles also arc found in the gastric contents. 1 I n 
the accompanying illustration (Fig. 39) a specimen obtained from a 

Fig. 40. 




A fragment of mucous membrane derived from the stomach. (Ewald.) 

carcinomatous patient is represented, which is readily distinguished 
from similar fragments of mucous membrane (Fig. 40). 

EXAMINATION OF THE MOTOR POWER OF THE 
STOMACH. 

Under physiological conditions the stomach should contain but 
few particles of food, or none at all, six hours after the ingestion of 
Riegel's meal, or one and one- half to one and three-quarters hours 
after that of Ewald. A delay in the propulsion of the gastric contents 
may be referable to the existence of a simple atony or to dilatation 
of the stomach. According to Boas, an atony may usually be diag- 
nosed if, following the exhibition of a supper consisting of bread and 
butter, cold meat, and a large cupful of tea, the stomach is found 
empty in the morning, providing, of course, that symptoms exist 
which point to atony or dilatation. It should be remembered, however, 
that in cases of acute and subacute gastritis, in the absence of a more 
serious lesion, food may be found in the stomach twenty-four hours 
after its ingestion. A dilatation may, on the other hand, be diagnosed 
if the stomach under the same conditions contains a considerable 
amount of food. In such cases it happens that not only remnants 
of the test-supper, but remains of meals taken one, two, three, or 
even more days previously are found. The quantities, moreover, 
which may be obtained at the time of examination are often surpris- 
ingly great, and may amount to sixteen pounds or more. Portel 
cites the case of the Due de Chausnes, one of Paris' greatest gour- 
mands, whose stomach could hold 4.5 liters — i. e., 8 pints. 

The following methods may be employed for the purpose of testing 
the motor power of the stomach : 

1 P. Cohnheim, ,: D. Bedeutung kleiner Schleimhautstuckchen f. d. Diaguostik d. 
Magenkrankheiten." Arch. f. Verdauungskiunkluiten, 1896, vol. i. p. '271. 



201 THE GASTRIC JUICE AXE GASTRIC CONTENTS. 

Leube's Method." — Six hours after the ingestion of Riegel's meal 
the stomach is washed out with about 1000 e.c. of water. In the 
presence of only slight tract- : food the motor power may be 
regarded as normal. This method is undoubtedlv the most conven- 
ient for practical purposes. 

The Salol Test of Ewald and Sievers.- — This test is based upon 
the observation that salol, a compound ether of salicylic acid, is de- 
composed into phenol and salicylic acid only in an alkaline medium. 
As the salicylic acid is eliminated in the urine as salicyluric acid, it 
is possible to determine the time of the pas-age of the salol from the 
stomach into the small intestine. 

A capsule containing 1 gramme of salol is given to the patient 
immediately after his breakfast or dinner, when separate portions of 
mine, passed one-half, one horn', two hours, and twenty-four hours 
later, are tested by adding a small amount of a solution of ferric 
chloride. In the presence of salicyluric acid a violet color results. 
Under normal conditions a positive reaction is obtained after from 
forty-five to seventy -rive minutes. A further delay may usually be 
regarded as indicating the existence of rnotor insufficiency. If no 
result is obtained after twenty-four hours, a pyloric stenosis undoubt- 
edly exists. Under normal conditions, furthermore, it will be 
observed that the salol elimination is completed after twenty-four 
hours, while in cases of dilatation of the stomach a positive reaction 
may still be obtained after thirty hours. It is thus possible to dis- 
tinguish between dilatation and descent of the stomach. 

The test, while it is convenient and usually yields fair results, is 
not altogether reliable, as the decomposition of the salol may at 
times occur in the stomach, owing to the presence of alkaline mucus, 
or may be delayed in the intestines owing to the existence of acid 
fermentation, etc. 3 

EXAMINATION OF THE RESORPTIVE POWER OF THE 

STOMACH. 

T<:> this end. a capsule containing 0.2 gramme of potassium iodide 
is _:ven to the patient shortly before a meal, and the saliva examined 
for the presence of potassium iodide at intervals of from two to three 
minutes 4 (see Saliva, paee 142). 

Under normal conditions a violet color is obtained after from six 
and one-half to eleven minutes, and a bluish tint after from seven 
and one-half to fifteen minutes. In pathological conditions a delayed 
reaction is observed in almost all diseases of the stomach, and is 

1 Leube. Dentsch. Arch, f klin. Med., vol. xxxiii. 

2 Ewald u. Siever?. Therap. Monats.. August. 1887. 

3 Bmnner. Deutseh. nied. Woch.. 1559. Huber. Correspondenzbl. f. schweizer Aerzte, 
1890. 

* Penzoldt, Berlin, klin. Woch., 1592. Faber, Inaug. Diss., Erlangen, 1882. 



INDIRECT EXAMINATION OF THE GASTRIC J TICK 205 

especially marked in cases of dilatation and carcinoma, less so in 
chronic gastritis, and variable in nicer. 

Absolute conclusions, however, cannot be drawn from results thus 
obtained, as a normal reaction-time has also been observed in cases 
of dilatation and chronic gastritis. 

INDIRECT EXAMINATION OF THE GASTRIC JUICE. 

Gunzburg's Method. 1 — In those cases in which for any reason the 
introduction of the stomach-tube is contraindicated or impracticable 
the following method, suggested by Gunzburg, may be employed : 

A tablet of 0.2 to 0.3 gramme of potassium iodide is inserted into 
a piece of the thinnest possible, strongly vulcanized rubber-tubing, 
measuring about 2.5 em. in length. The ends are folded as shown 

Fig. 41. 




A fibrin-potassiuui-iodide package of Gunzburg. 

in Fig. 41, and the little package tied with three threads of fibrin 
hardened in alcohol. Every package should be examined before 
use, by immersion in warm water for several hours, to determine its 
tightness, testing for the presence of potassium iodide by means of 
starch-paper and fuming nitric acid. One of these packages is 
swallowed by the patient three-quarters to one hour after an Ewald 
tot-breakfast, and the saliva tested for potassium iodide at intervals 
of fifteen minutes, until a positive result is reached or until six hours 
have elapsed. It is unnecessary to wait longer than six hours. In 
the presence of free hydrochloric acid the threads of fibrin are dis- 
solved and the potassium iodide absorbed. Under normal conditions 
a positive reaction is obtained after from one to one and three-quar- 
ters hours, while anachlorhydria undoubtedly exists if no result is 
obtained within five or six hours. In cases of hypochlorhydria the 
reaction is delayed for more than two to three hours. Gunzburg 
further advises that the resorption-test with potassium iodide be 
also made, and that the reaction-time be deducted from that taken 
up in the elimination of the iodide contained in the package. Sev- 
eral tests, moreover, should be made in the same case. 

I have had occasion to experiment with packages obtained from 
Germany, and manufactured according to the directions of Gunz- 
burg. 2 In most of the packages the threads of fibrin had become 
brittle and were broken in transit. The results obtained with about 
twenty intact specimens, however, were entirely satisfactory, and it 

1 Sahli. Klinische Untersucbungsmetboden, 1900, p. 399. 

2 Gothe Apotbeke, Frankfurt a. M. 



206 THE GASTRIC JUICE AND GASTRIC CONTENTS. 

is to be regretted that the packages cannot be obtained in the 
American market. 

Similar packages have been constructed by Sahli. 

Reach has of late made use of barium iodate and the oxyiodate of 
bismuth for the same purpose, but without enclosing the substance 
in rubber. As hydrochloric acid only is capable of liberating the 
iodine from these bodies, they may be employed instead of the Gunz- 
burg packages. As a result of his examinations, he concludes that 
in the presence of hydrochloric acid iodine can thus be demonstrated 
in the saliva within eighty minutes. He finds, however, that at 
times the reaction occurs later than might have been supposed from 
the amount of hydrochloric acid found. 

Simon's Method. — Personal researches have led me to believe that 
a close relation exists between the elimination of indican in the 
urine and the amount of free hydrochloric acid in the gastric con- 
tents. 1 The results reached may be summarized as follows : 

1. Euchlorhydria is associated rarely with an increased elimina- 
tion of indican. 

2. In cases of simple neurotic hyperchlorhydria a subnormal or 
normal amount of indican is the rule. 

3. In cases of hyperchlorhydria associated with ulcer an increased 
indicanuria is observed quite constantly. 

4. Anachlorhydria referable to organic lesions of the stomach is 
associated almost invariably with a highly increased indicanuria. 

5. Hysterical anachlorhydria may be associated with the elimina- 
tion of a normal or increased amount of indican. 

6. In cases of hypochlorhydria increased indicanuria is the rule. 
Given as premises : 

1 . That a resorption of decomposing pus is not taking place any- 
where within the body, as such a process in itself is capable of caus- 
ing an increased elimination of indican. 

2. That a stenosis of the small intestine or a high degree of gas- 
tric atony does not exist. 

3. A normal mixed diet, containing no excessive amounts of red 
meat (see Indicanuria). 

1 C. E. Simon, " The Modern Aspect of Indicanuria, with Special Eeference to the 
Relation of Indicanuria and the Acidity of the Gastric Juice," Am. Jour. Med. Sci., 
1895, vol. ex. p. 481. 



CHAPTER IV. 
THE FECES. 

The feces constitute a mixture of undigested particles of food and 
unabsorbed secretions of the gastro-intestinal tract, together with 
intestinal mucus, epithelial cells, and bacteria. 

EXAMINATION OF NORMAL FECES. 

General Characteristics. 

Number of Stools. — The number of stools which may be passed 
in the twenty -four hours is subject to wide variation, even under 
physiological conditions, but is usually constant for one and the same 
individual. One or two stools pro die may be regarded as normal. 
Exceptions, however, are frequent. Persons are thus met with who 
have but one stool every two to four days, and cases are on record 
in which only one passage occurred every seven to fourteen days, 
the individuals evidently enjoying perfect health. On the other 
hand, the number of stools may be increased to three or four under 
strictly normal conditions. Hence the importance of accurately ascer- 
taining the habitual number of stools in every individual. It would 
thus be manifestly wrong to regard the passage of three stools daily 
as diarrhoea, or the passage of only one stool in forty-eight hours as 
constipation, if this number has been habitual throughout life. 

Whether or not it is permissible to regard as normal those rare 
instances in which only one stool occurs every two to six weeks, or 
even less frequently, is rather doubtful. 

Amount. — In those cases in which more than one or two stools 
occur in twenty-four hours it is well to ascertain the amount actually 
passed. The normal amount varies between 100 and 200 grammes. 1 
This quantity is increased by a diet rich in vegetable and starchy 
foods, and is diminished by one rich in animal proteids, so that 60 
and 250 grammes may be regarded as the extreme limits in health. 
Such amounts as 500 and 1000 grammes are certainly abnormal. 

Consistence and Form. — The consistence of a stool depends 
essentially upon the amount of water present, and hence upon the 
character of the food ingested, being softer with a purely vegetable 

1 Voit, Zeit. f. Biol., vol. xxv. p. 264. 

207 



:: - zzz zz:z> 

diet (80-&0 per cent- of water) than with a diet rich in animal proteids 
(60-65 per cent.). With a mixed diet the amount of water corre- 
sponds to about 75 per cent. As a general rule, normal stools 
exhibit the characteristic cylindrical form and are fairly firm. Mushy 
stools, however, are also seen quite frequently, and round,, scybalous 
masses, although far more common in constipation, may likewise be 

Odor. — The repugnant odor of the feces is, to a large extent, due 
to the presence of indol and skatol ; hydrogen sulphide, methane, and 
traces of phosphin may add still further to their disagreeable odor. 

Color. — The color of the feces varies, according to the nature of 
the mod ingested, from a light to almost a blackish brown, a firm 
si 1 being in general darker than a thin stool. A stool that has 
remained exposed to the air is also somewhat darker upon its outer 
surface than in its interior, owing to processes of oxidation. In 
niirsmg-iniants, in consequence of the exclusive ingestion of milk, 
the color is light yellow. 

Under normal conditions the color is never due to native biliary 
coloring-matter, but is largely dependent upon the presence of uro- 
bilin (see page 220). It is, furthermore, influenced by the nature 
of the food, chlorophyll tending to produce a greenish color, starches 
a yellowish tinge. If much blood is present in the food, the feces 
may be almost black, owing to die formation of hsematin. Huckle- 
berries and red wine likewise produce a blackish color, chocolate 
and cocoa a gray ; preparations of iron, manganese, and bismuth 
color the feces dark brown or black, owing to the formation of sul- 
phides of these metals ; the green color of calomel stools was formerly 
supposed to be due to the formation of a sulphide, but is more likely 
caused by the presence of biliverdin. Santonin, rheum, and senna 
produce a yellow color. 

Macroscopica,.!. Cor.s:::uer.os 

Alimentary Detritus. — Upon farther examination of the feces it 
is possible to find visible to the naked eye undigested particles of 
food, which are partly indigestible and partly digestible, such as 
stones of cherries, grape-seeds, woody vegetable fibre, the skins of 
berries, large pieces of connective tissue, undigested pieces of apple, 
pear, potato, grains of corn, etc. Such undigested food is found in 
abundance when insufficiently masticated or taken in excessive 
amounts. 

Flakes of casein, recognizable with the naked eye, are also fre- 
quently seen. Care should be taken not to confound these with 
particles of stool composed of fatty acid crystals. This mistake is 
often made, and can readily be avoided by a microscopical or chemical 
examination (see page 229). 



EXAMINATION OF NORMAL FECKS. 



209 



Foreign Bodies. — In children, the insane, in cases of hysteria, 

and even in people who are apparently possessed of their normal 
senses, the physician must be prepared to find at times all kinds of 
foreign bodies, such as pins, coins, buttons, false teeth, tooth-plates 
with ragged edges, and even dirk-knives, all of which have been 
known to pass through the alimentary canal with perfect safety. It 
must not be forgotten, however, that in certain eases of hysteria 
bodies may be shown by patients which they claim have passed by 
the rectum, but which have been wilfully added to the stools, such 
as snakes, frogs, etc. 



Microscopical Constituents. 

Constituents derived from Food. — Microscopically, indigestible 
and undigested constituents of food may be seen (Fig. 42), such as 
the framework of vegetable material, sometimes still containing 
starch-grannies or remnants of chlorophyll; muscle-fibres, usually 
colored yellow and more or less altered in structure. Elastic-tissue 
fibres are readily recognized by their double contour and bold out- 
lines. Connective-tissue fibres of the white fibrous variety can also 
generally be distinguished ; wheu present in large quantities, how- 
ever, they are usually indicative of some digestive derangement, un- 
less they are observed following the ingestion of a meal particularly 
rich in meat. Flakes of casein also are seen frequently. 

Fig. 42. 




Collective view of the feces. (Eye-piece IT I., objective 8 A. Reichert.) a, muscle-fibres ; 
o, connective tis-ue : c. epithelium : '/. white blood-corpuscles; '. spiral cells;/, i, various 
vegetable cells : k, triple phosphate crvstals in a mass of various micro-organi>ms ; /, diatoms. 
(v. Jaksch.) 

Muscle-fibres are found in every stool whenever meat has been 
eaten. Under normal conditions, however, they are not numerous, 
unless particularly large quantities have been ingested. Their ap- 
pearance under the microscope may vary considerably. On the one 
hand, fibres are met with which still retain their characteristic 

14 



210 THE FECES. 

features ; others are split up either partially or entirely into the 
well-known disks ; but more common than both are more or less 
roundish, yellow, apparently homogeneous fragments, which at first 
sight do not resemble muscle-fibres in the least. Upon closer in- 
vestigation, however, their true nature will become apparent. It 
will then be seen that two of the sides in some portions at least are 
more or less parallel, and if the specimen is examined with an oil- 
immersion lens some traces of cross-striation can probably always 
be discovered. 

Isolated starch-granules are scarcely ever found under normal 
conditions, excepting in young children who have been fed with much 
starchy material. Starch-granules enclosed in vegetable cells are 
likewise not found as a general rule, but are more common than the 
isolated granules. The presence of either in large numbers is usually 
indicative of the existence of some pathological condition affectiug 
the gastro-intestinal tract. Their presence is easily recognized by 
treating microscopical preparations with a solution of iodo-potassic 
iodide ( Lugol's solution), when the granules or fragments will assume 
a blue color. 

The presence of fat in the feces is quite constant, even in health. 
It may occur in the form of needle-like crystals, as fat-droplets, or 
as polygonal masses which are highly refractive and often colored 
yellow or a yellowish red. Their true nature is easily recognized 
by adding a drop of concentrated sulphuric acid and heating, when 
they are transformed into the characteristic fat-droplets. 

Morphological Elements derived from the Alimentary Canal. 
— 1. Epithelial cells. "Well-preserved cylindrical or goblet cells are 
only exceptionally found in the feces, while transition-forms from 
the normal cells to mere spindles, in which a nucleus can no longer 
be recognized, are observed quite constantly. These degenerative 
changes, according to Xothnagel, 1 are the result of an abstraction 
of water from the cells, which may alter their appearance to an 
extent that only the experienced eye is capable of recognizing their 
true character. Pavement epithelial cells, when present, are derived 
from the anal orifice. 

2. Leucocytes are almost always absent in normal stools or pres- 
ent only in very small numbers. 

3. Red blood-corpuscles in very small numbers are occasionally 
observed under apparently normal conditions, but are then of no 
significance. 

4. In every stool a large number of structureless granules may 
be seen, lying either by themselves or collected into heaps ; they are 
designated as detritus. 

Crystals. — Xeedle-like crystals of free fatty acids, and the cal- 

1 Xothna.irel. Beitrage z. Physiol, u. Pathol, d. Darmes. Hirschwald. Berlin. 1884, 
and Specielle Pathol, u. Therap.. Holder. Wien. 1895, vol. xvii. Pt. 1. 



EX. 1 MIX. i TION OF NORM. 1 I FE( 'AW. 



211 



oium and magnesium salts of the higher members of this group, 
occurring cither singly or arranged in sheaves, may he found in 
every stool (Fig. 43). They are of no significance unless present 
in large uumbers. Nothnagel l speaks of the frequent occur- 
rence of certain calcium salts (of fatty acids, as he believes) in 
normal as well as pathological stools. He states that they arc 
almost always bile-stained, and occur in irregular, sometimes ellip- 
tical, oval, or circular masses, in which a crystalline structure 
cannot he distinguished. They are apparently of no importance. 
Quite common, also, are crystals of neutral calcium phosphate and 

Fig. 43. 






&JM 



VWvM' 



h . 






Fatty crystals obtained from the feces. 

ammonio-magnesium phosphate, the former occurring in the form 
of more or less well-defined wedge-shaped crystals collected into 
rosettes, the latter presenting the well-known coffin-shape when the 
stool is mushy, while in firm stools irregular fragments mostly are 
found. At one time the ammonio-magnesium phosphate crystals 
were supposed to be characteristic of typhoid stools, but it is now 
known that they occur in normal feces, as well as under the most 
varied pathological conditions. Their presence is of no diagnostic 
significance. It is important to note that the neutral phosphates 
are never stained by bile-pigment, and the triple phosphates only 
in rare instances. Both are easily soluble in acetic acid. Crystals 
of calcium oxalate may be found in abundance following the inges- 
tion of certain vegetables, such as sorrel and spinach. They are 
usually found imbedded in the vegetable debris. They are readily 
recognized * by their characteristic envelope-form, their insolubility 
in acetic acid, and their solubility in hydrochloric acid. Not infre- 
quently they are bile-stained. 

1 Loc. cit. 



212 THE FECES. 

Calcium lactate is frequently seen in the stools of children re- 
ceiving a milk-diet ; they occur in the form of sheaves composed of 
radiating needles. Calcium carbonate is rarely observed, but occa- 
sionally occurs in the form of amorphous granules or dumb-bell- 
shaped crystals. Calcium sulphate crystals are likewise rare, but may 
be produced artificially by the addition of sulphuric acid, when beauti- 
ful needles and platelets may be observed. Cholesterin, while always 
present in solution, is rarely observed in crystalline form (Fig. 41). 
I have found it only twice in several hundred examinations. Hsema- 
toidin crystals are never found in normal stools. Charcot-Leyden 
crystals may be found under pathological conditions ; according to 
my experience, they are never seen in normal stools. 

Parasites. — The parasites which occur in normal feces may be 
divided into vegetable and animal parasites. 

Vegetable Parasites. — These are always present in enormous 
numbers. What relation they bear to the process of digestion is 
still an open question. The idea held by Pasteur and many others, 
that animal life cannot go on in the absence of bacteria from the 
digestive tract has been disproved by Nuttall and Thierf elder. 1 A 
guinea-pig, removed by Caesarean section from the uterus of the 
mother-animal, under antiseptic precautions, was placed in a ster- 
ilized glass cage and nourished for a week with sterilized food. The 
air which the animal breathed w r as likewise sterilized. During this 
week the animal consumed about 330 c.c. of milk and appeared to 
be normal in every respect. At the expiration of the week it was 
killed, when a microscopical examination of the intestinal contents 
revealed the absence of bacteria. Culture-experiments also were 
negative. 

Macfadyen, Nencki, and Sieber 2 likewise found that their now so 
often quoted fistula patient continued in good health, and even 
gained flesh, although the entire large intestine, in which bacterial 
activity is always greatest, was isolated for a period of many weeks. 

Fungi. — Fungi, with the exception, perhaps, of the Oi'dium albi- 
cans, which has at times been observed, are rarely found in the feces. 

Schizomycetes. — Saccharomyces cerevisise is one of the normal 
constituents of the feces, and is found in its characteristic forms, 
three or four buds, however, being but ordinarily observed. Owing 
to the glycogen present in their substance, they assume a mahogany 
color when treated with a solution of iodo-potassic iodide. They 
should not be confounded with a class of bacteria which closely re- 
semble the saccharomyces in general appearance, but are colored blue 
when treated in the same manner (see below). 

1 Nuttall u. Thierfelder, "Thierisches Leben ohne Bakterien im Darm," Zeit. f. 
physiol. Chem., 1896, vol. xxi. p. 109, and 1897, vol. xxii. p. 62. 

2 Macfadyen, Nencki, u. Sieber. "Untersucbungen iiber die cbemischen Vorgange 
im menscblichen Diinndarm," Arch. f. exper. Path. u. Pharmakol., 1891, vol. xxviii. 
p. 311. 



EXAMINATION OF NORMAL FECES. 213 

'ganisms xar'i^o^jv 
which are found in the feces. Their number is truly enormous. 
Sucksdorff thus found in his own person that on an average 53,124,- 

000,000 were 1 eliminated in the twenty-four hours under normal 
conditions. About 97 per cent, of these are directly derived from 
the ingested food, and the remaining 3 per cent, from swallowed 
saliva. If we recall the strongly bactericidal power of the gastric 
juice, such an observation must at first sight appear most surprising. 
It should be remembered, however, that the spores of the bacteria 
are tar less susceptible to the action of hydrochloric acid, and that 
large amounts of the ingesta are carried into the small intestine at 
a time already, when hydrochloric acid has not as yet appeared in 
the free state. 

On the whole, the bacteriological flora of the intestinal contents 
is fairly constant, but, as in the other cavities and channels of the 
body where bacteria are invariably met with, transient guests are 
also not uncommon. The majority of the bacteria which are here 
encountered are, as a general rule, harmless ; but it is important to 
note that under suitable conditions a number of these may develop 
pathogenic properties. Broadly speaking, the bacteria which may 
be found normally in the feces can be divided into two classes. 
Those belonging to the first order are stained a yellow or a yel- 
lowish brown with iodo-potassic iodide, while those belonging to 
the second class are colored blue or violet by the same reagent. To 
the former belong the Bacterium termo, the Bacillus subtil is, and a 
large number of micrococci ; into a description of these it is not 
necessary to enter at this place. 1 Under the second heading v. Jaksch 2 
describes the following forms : 

1. Micrococci occurring in the zoogleea stage, which are colored 
a violet red. 

2. Short, thin rods, tapering slightly at both ends, and in their 
microscopical appearance much resembling the bacillus of the septi- 
caemia of mice ; sometimes they contain one or two little bodies, 
which are not stained by the reagent. 

3. Short or long rods, which resemble the Leptothrix buocalis in 
their behavior toward iodo-potassic iodide. 

4. Bacilli resembling the Bacillus subtilis. 

5. Bacillus butyricus. This micro-organism, according to Brieger, 
is the cause of butyric acid fermentation. It occurs in the form of 
broad rods with rounded extremities, but may also be elliptical or 
spindle-shaped. With LugoPs solution it is colored blue or violet, 
either entirely or only in its central portion. 

6. Large round forms, characterized, when unstained, by a pale 
lustre, and which very much resemble yeast-cells (see above). 

1 Fliig<:<\ Die Microorganismen. 

2 v. Jaksch, Kliuische Diaguostik, 1896. 



214 THE FECES. 

7. Micrococci, which assume a reddish, but not very pronounced 
tint. 

It should be mentioned that this second class of micro-organisms 
is not so largely represented in the feces as the first. 

To speak more specifically, the following bacteria have thus far 
been isolated from the feces : the Bacillus coli communis, Bacterium 
lactis aerogenes, Bacillus subtilis, Proteus vulgaris, Bacillus putrifi- 
cus coli, Bacillus licjuefaciens ilei, Bacterium ilei, Bacterium ovale 
ilei, Bacillus gracilis ilei, the veil bacillus of Escherich, Bacillus 
butyricus, Bacillus Uptadel ; Streptococcus coli gracilis, Strepto- 
coccus coli brevis, Streptococcus liquefaciens ilei, Streptococcus pyo- 
genes duodenalis, Staphylococcus liquefaciens albus, Staphylococcus 
liquefaciens flavus, Micrococcus ovalis, the porcelain-coccus of 
Escherich, tetrad en ococcus. In addition, various other bacteria have 
been found, but have not as yet been obtained in pure culture. This 
is true more particularly of certain forms of spirillum. 

The specific pathogenic bacteria which may be found in the feces, 
as well as those above mentioned, which may at times develop 
pathogenic properties, will be described in detail later on. 

Animal parasites are probably never present under strictly normal 
conditions. 

Chemistry of Normal Feces. 

Reaction. — The reaction of the feces is usually alkaline, sometimes 
neutral, rarely acid, the alkalinity being due to ammoniacal fermen- 
tation, the acidity to lactic and butyric acid fermentation, taking 
place in the intestines. In infants the stools are normally acid. 

General Composition. — The following table, taken from Gautier, 
will give an idea of the composition of fresh feces, calculated for 
1000 parts by weight : 

Adult man. Suckling. 

Water 733.00 851.3 

Solids 267.00 148.7 

Total organic material 208.75 137.1 x 

Total mineral material 10.95 2 13.6 

Alimentary residue 83.00 

The organic material yielded : 

Aqueous extract 53.-10 53.50 

Alcoholic extract 41.65 8.20 

Ethereal extract 30.70 17.60 3 

In addition, there are gases, which vary in quantity according to 
the nature of the food ingested, such articles as beans, heavy bread, 
potatoes, etc., increasing the amount very considerably. 

1 Including ."4 parts of mucin, epithelium, and calcareous salts. 

2 Not comprising earthy phosphates. 

3 Of this, 3.2 is cbolesterin. 



EXAMINATION OF NORMAL FECES. 215 

Milk diet Meat diet. Vegetable diet. 
Per inn. Per cent. Per cent. 

Carbon dioxide 8-16 8-13 21-34 

Hydrogen 43-54 0.7-3 1.5-4 

Marsh gas 0.09 26-37 44-65 

Nitrogen 36-38 45-64 10-19 

Of these gases, carbon dioxide is partly referable to alcoholic and 
butyric acid fermentation, and partly to albuminous putrefaction, 
taking place in the intestines. Marsh gas is formed during the fer- 
mentation of cellulose, while the nitrogen has partly been swallowed 
and is partly referable to albuminous putrefaction. A portion also 
is probably derived from the blood, and it may be mentioned in this 
connection that the enormous quantities of carbon dioxide so often 
discharged in cases of hysteria are undoubtedly referable to this 
source, the gas passing from the blood through the gastro-intestinal 
mucous membrane into the stomach and intestines. 

In order to give a general idea of the chemical constituents of the 
feces these may be divided into : 

1. Food material which could be assimilated, but which was taken 
in excess, such as starches, fats, and a small amount of non-assimi- 
lated albuminous material. 

2. Indigestible substances, such as chlorophyll, gums, pectic 
products, resins, various coloring-matters, nucleins, chitin, and 
insoluble salts, viz., silicates, sulphates, earthy phosphates, ammonio- 
magnesium phosphate, etc. 

3. Products derived from the digestive canal, as mucus, partly 
transformed biliary acids, dyslysin, cholesterin, lecithin. 

4. Substances in process of absorption, as emulsified fats, fatty 
acids, leucin, and biliary acids. 

5. Products of decomposition, referable to microbic activity, such 
as fatty acids, comprising the entire series from acetic to palmitic 
acid, the latter being especially abundant ; lactic acid, phenol, cresol, 
indol, skatol, excretin, leucin and tyrosin ; phenol-propionic, phenyl- 
acctic, hydro paracumaric, and parahydroxyl-phenyl-acetic acids ; 
ammonium carbonate, and ammonium sulphide. 

6. Products of metabolism eliminated through the intestines : 
urea, uric acid, and xanthin-bases. 

7. Pigments: stercobilin, hsematin, hydrobilirubin, coloring-mat- 
ter derived from the blood, and, in abnormal conditions, bile-pig- 
ments. 

8. Water. 

9. Gases, as carbon dioxide, marsh gas, hydrogen, and nitrogen. 
The study of these substances as a whole, as well as in detail, 

i< of great importance, not only from the standpoint of the physiolo- 
gist, but also from that of the clinician, giving, together with a 
careful urinary analysis, the clearest idea of the metabolic process a 
taking place in the body. 



216 THE FECES. 

The chemical study of the feces, however, has so far received but 
little attention, and data of practical importance have scarcely been 
obtained from the work accomplished. The field is nevertheless an 
important one. 

It is impossible to give here a detailed description of the various 
chemical constituents which have been mentioned. Only the most 
important ones, and those especially interesting from a physiological 
and pathological standpoint, will be considered. 

Phenol, Indol, and Skatol. — Phenol, indol, and skatol are 
formed during the process of albuminous putrefaction, and are con- 
stant constituents of the feces. A small portion is resorbed from 
the intestinal canal, and appears in the urine in combination with 
sulphuric acid and to a slight extent also with glucuronic acid. Pre- 
viously, however, the indol and skatol are oxidized to indoxyl and 
skatoxyl, respectively (see Urine). 

To demonstrate the presence of phenol, indol, and skatol in the 
feces, we may proceed as follows : 

The feces are diluted with water, acidified with phosphoric acid, 
and distilled. The volatile fatty acids present, together with phenol, 
indol, and skatol, pass over. The distillate is then neutralized with 
sodium carbonate and again distilled. During this process phenol, 
indol, and skatol pass over, the fatty acids remaining behind as 
sodium salts. In order to separate the phenol from indol and skatol, 
the distillate is alkalinized with potassium hydrate and again distilled. 
The phenol now remains behind, and may be obtained in pure form 
by distilling with sulphuric acid ; in this final distillate its presence 
may be demonstrated by the following reactions : 

1. With ferric chloride phenol yields an amethyst-blue color. 

2. With bromine-water a crystalline precipitate of tribromophenol 
is obtained. 

3. Treated with Millon's reagent — i. e., the acid mercuric nitrate — 
a red color develops. 

Indol and skatol pass over after treating the above mixture of 
the three with potassium hydrate and distilling. These two bodies 
may then be separated from each other by taking advantage of their 
different degrees of solubility in water. 1 

Indol forms small plates, melting at 52° C, which are easily 
soluble in hot water, alcohol, and ether ; its odor is feculent. 

Reactions of indol : 1. When treated with nitric acid and a little 
sodium nitrite a crystalline red precipitate of the nitrate of nitroso- 
indol is obtained. 2. A small piece of pine wood moistened with 
an alcoholic solution of indol acidified with hydrochloric acid is 
colored a cherry red. 

Skatol crystallizes in plates which melt at 95° C. They are soluble 
with more difficulty in water than indol, and emit a feculent odor. 

1 C. E. Simon, Physiological Chemistry, Lea Bros. & Co., 1901. 



EXAMINATION OF NORMAL FECES. 217 

Reactions of skatol : 1. With nitric acid and sodium nitrite only 
a milky cloudiness results. 2. Pure skatol does not color pine wood 
moistened with hydrochloric aeid ; but if a bit of the wood i> satu- 
rated with a dilute alcoholic solution of skatol and then immersed 
in strong hydrochloric acid, it assumes a cherry-red and later a 
bluish-violet color. 3. With nitric acid of a specific gravity of 1.2 
it gives a marked xanthoproteic reaction on boiling — i. e., a yellow 
color which turns to orange upon the addition of an excess of 
ammonia. 

The determination of cresol in the presence of phenol, together 
with which it is obtained, is, when only small quantities of these 
substances are present, a difficult matter. They may be separated 
from each other by transforming both into their sulpho-acids ; the 
barium salt of para-sulpho-phenol is practically insoluble in barium 
hydrate. 

Fatty Acids. — The chemical composition of fatty acids present 
in the feces, as well as the relation existing between tkern, is shown 
in the table below. The formula C„H 27l4 . 1 , COOH, or C„H 2 „0 2 ex- 
presses their general structure. 

Formic acid H.COOH = C H 2 2 

Acetic acid CH 3 .COOH = C 2 H 4 2 

Propionic acid CH 3 .CH,.COOH = C 2 H 2 

Butyric acid CH 3 .(CH.,) 2 .COOH = C 4 H 8 9 

Isobutvric acid (CH 3 ) .CH.COOH = C 4 H 8 O t 

Valerianic acid CH,.(CH 2 ) 3 .COOH = C 5 H„,0 2 

Caproicacid CH 3 .(CH 2 ) 4 .COOH = C 6 H 12 2 

Capric acid CH 3 .(CH 2 ) 8 .COOH = C 10 H 20 O 2 

Palmitic acid CH 3 .(CH 2 ) u .COOH = C 16 H 32 2 

Stearic acid CH 3 .(CH 2 ) 16 .COOH — C 18 H 36 G 2 

These acids are derived partly from fats, partly from carbohydrates, 
and to some extent also from proteids. 

Separation of the Fatty Acids from the Feces. — If the distillate, neu- 
tralized with sodium carbonate, referred to in the above method, is 
again distilled, the sodium salts of the fatty acids remain behind : 

2C 15 H 31 .COOH + Na 2 C0 3 =, 2C 15 H 31 .COONa + H 2 + C0 2 . 

The solution is then evaporated to dryness on a water-bath, the 
residue extracted with alcohol, the alcohol evaporated, and the final 
residue dissolved in water. This solution may now be further ex- 
amined. In order to separate the different fatty acids from each 
other, it is best, if the quantity is sufficiently large, to transform 
them into their silver or barium salts, and to separate these by their 
varying degrees of solubility in water or by fractional distillation. 

General properties of the fatty acids ■ they are all monobasic, 
and soluble in water, alcohol, and ether. Their alkaline salts are 
readily soluble in water and alcohol, but insoluble in ether. The 
silver salts are dissolved with difficulty. 



218 THE FECES. 

1. Formic arid is a colorless liquid, of a penetrating odor, boil- 
ing at 100° C. A concentrated solution of its alkaline salts is 
precipitated by silver nitrate : the silver salt becomes black on 
standing, and reduction takes place at once upon the application of 
heat. Treated with ferric chloride in neutral solution it yields a 
blood-red color, which disappears on boiling, while a rust-colored 
precipitate is formed at the same time. 

2. Acetic acid is a liquid of a pungent odor, which boils at 
119° C. After neutralization a blood-red color is obtained on the 
addition of ferric chloride. Neutral solutions of its salts with the 
alkalies yield a precipitate with silver nitrate, which is soluble in 
hot water without reduction taking place. 

3. Propionic acid is an oily fluid, boiling at 11 7 c C. AVith 
ferric chloride no red color results; with silver nitrate it behaves 
like formic acid. 

4. Butyric acid is an oily liquid, boiling at 137 c C. ; its odor is 
similar to that of rancid butter. When treated with an acid, its 
salts give off the characteristic odor ; with ferric chloride it yields 
no red color ; with silver nitrate its alkaline salts form a crystalline 
precipitate which is insoluble in cold water. 

5. Valerianic acid boils at 176.3° C, and has a penetrating, dis- 
agreeable odor. Its silver salt crystallizes in plates, which are 
soluble with difficulty. 

Cholesterin. — Cholesterin (C^H^O) occurs in small amounts in 
almost all animal fluids. It is found also in various tissues of the 
body, especially in the brain. Its origin and mode of formation in 
the various organs of the body, as well as the cause of its presence 
in the alimentary canal, are as yet unknown. It crystallizes in 
colorless, transparent plates, the margins and angles of which usually 
present a ragged appearance (Fig. 44). It is practically insoluble 
in water, dilute acids, and alkalies. In boiling alcohol it is readily 
soluble and crystallizes out from this solution on cooling ; it is 
likewise easily soluble in ether, chloroform, and benzol. 

In order to obtain cholesterin from the feces, in which it is always 
present, though rarely in crystalline form, the fatty acids, phenols, 
indol, and skatol must first be distilled off, as described, when the 
residue is strongly acidified with sulphuric acid, extracted with 
alcohol, and then with ether. The ethereal extract is filtered, the 
ether distilled off. and the residue digested with sodium carbonate, 
in order to transform into their salts any fatty acids which may still 
be present. Thi> mixture is then evaporated to dryness, and again 
extracted with ether. The alcoholic extract above mentioned is also 
filtered, supersaturated with sodium carbonate, the alcohol distilled 
off, the residue dissolved in water and likewise extracted with ether. 
In the watery alkaline residue there remain bile-acids, oleic, palmitic, 
and stearic acids, which can be separated by transforming them into 



EXAMINATION OF NORMAL FECES. 219 

their barium salts. The cholesterin and fats pass over into the 
ether. This is distilled off and the residue treated with au alcoholic 
solution of potassium hydrate. The alcohol is evaporated on a 
water-bath, the remaining liquid diluted with water and again ex- 
tracted with ether. The fats remain in the aqueous solution as 
soaps, while the cholesterin has passed into the ether. 

Tests for cholesterin: 1. Under the microscope add a drop of 
concentrated sulphuric acid to some of the crystals; they gradually 
disappear, the edges assuming a yellowish-red color. 

2. Dissolve a tew crystals in chloroform, add concentrated sul- 
phuric acid, and shake the mixture : the chloroform assumes a blood- 
red to a purplish-red color, while the sulphuric acid at the same time 
shows marked fluorescence. 

To isolate the fatty acids, the solution of soaps obtained above is 
acidified with dilute sulphuric acid, when the fatty acids which have 

Fig. 44. 



■v.M 










Cholesterin crystals. 

separated out may be filtered off and identified individually by their 
boiling-points and the analysis of their barium salts. 

The final filtrate, when neutralized with ammonium hydrate, con- 
tain- glycerin. 

The Biliary Acids. — The biliary acids found in the feev^ are : 
glycocholic acid ( C_,,H 4;i XO (; ), taurocholic acid (C 2(; H,.XS0 7 ), and 
cholalic acid (C 24 H 40 O.). 

The two former occur normally in the bile, and can be decomposed 
into cholalic acid and glycocoll, and cholalic acid and taurin, respec- 
tively ; as this process of decomposition takes place ordinarily in the 
intestines, the third acid — /*. c, cholalic acid — is always found in the 
feces. 

In order to demonstrate the biliary acids, the fatty acids, phenols, 
indol, and skatol are first removed by distillation with phosphoric 
acid. The residue is taken up with water and boiled, and the filtered 



220 THE FECES. 

liquid precipitated with lead acetate and a little ammonium hydrate. 
The biliary salts of lead are contained in the precipitate, from which 
they can be removed by washing with water and finally boiling the 
precipitate with alcohol. The washings are filtered and the lead salts 
transformed into sodium salts by treating the filtrate with sodium 
carbonate. After further filtration the filtrate is evaporated to dry- 
ness and the residue extracted with hot alcohol. Upon evapora- 
tion the salts of the acids sometimes crystallize out as such, while 
more often a dirty amorphous precipitate is obtained, which may be 
rendered crystalline by treating with ether. The amorphous residue, 
however, can be employed for making the necessary tests. 

Pettenkofer's Test. — A small amount of the substance is dissolved 
in water, and treated with two-thirds its volume of concentrated 
sulphuric acid, care being taken that the temperature does not exceed 
60° or 70° C. While stirring, a 10 per cent, solution of cane-sugar 
is added drop by drop. If biliary acids are present, the solution 
assumes a beautiful red color, which on standing turns a bluish violet. 
This test depends upon the action of furfurol, derived from the sul- 
phuric acid and cane-sugar, upon the biliary acids. 

Pigments. — The principal pigment of normal feces is termed 
stercobilin, and was first isolated from this source by Vanlair and 
Masius. 1 Owing to its great similarity to hydrobilirubin, it has even 
been regarded as identical with it, but Garrod and Hopkins 2 have 
now conclusively shown that whereas the urobilin of the urine and 
the stercobilin of the feces are identical in composition, as also in 
properties, they differ conspicuously from hydrobilirubin, and espe- 
cially in the much smaller percentage of nitrogen which they con- 
tain, viz., 4.11, as compared with 9.22 per cent. It is derived from 
bilirubin, and formed in the upper regions of the large intestine 
more especially, as the result of bacterial activity. 3 This explains 
the observations that as a rule the meconium and the solid excreta 
of the first day or two of life contain no urobilin, and that the 
pigment also disappears, when for any reason the bile is prevented 
from entering the intestinal canal. 

To isolate the pigment from the feces, the material is first extracted 
with alcohol. The alcoholic extract is evaporated to dryness ; the 
residue is extracted with water, the aqueous solution acidified with 
sulphuric acid and saturated with ammonium sulphate, when on 
shaking with chloroform or a mixture of chloroform and ether the 
pigment is taken up by the organic solvent. 

The free pigment is a brown amorphous substance of a character- 

1 Vanlair and Masius, Centralbl. f. d. med. Wiss., 1871, vol. ix. p. 369. 

2 F. G. Hopkins and A. E. Garrod, " On Urobilin," Jour, of Physiol., 1898, vol. xxii. 
p. 451. 

3 A. Schmidt, Verhandl. d. XIII. Congresses f. inn. Med., 1895, p. 820. Vaughan 
Harley, Brit. Med. Jour., 1896, vol. ii. p. 898. Macfadyen, Nencki, and Sieber, Arch, 
f. exper. Path. u. Pharmakol., 1891, vol. xxviii. p. 311. 



PATHOLOGY OF THE FECES. 221 

istic odor, and molts at a temperature below 100° C. On cooling, 

it forms a brittle, shellac-like material, which is said to be quite char- 
acteristic. It is soluble in ether, chloroform, water, and amy] 
alcohol. On treating its solutions with zinc chloride and ammonia 
a beautiful green fluorescence is obtained. Such solutions then show 
three bands of absorption, of which the one between Cand F is the 
most characteristic (see also Urinary urobilin). 

Haematoporphyrin, to judge from recent investigations by Stokvis l 
and Garrod, 2 is likewise a normal component of the feces, but oc- 
curs only in traces. Garrod states that with Saillet's 3 method, the 
basis of which is extraction with acetic ether, after the addition of 
acetic acid, he invariably found traces, comparable with those which 
normally are present in the urine. He also states that he found 
considerably larger amounts of the pigment in the meconium, both 
in that expelled during the first day or two of life, and in that re- 
moved from the intestines of stillborn infants. 

The presence of these normal traces has been referred by some to 
the ingested blood-coloring matter of red meat and vegetable chloro- 
phyll. Garrod, however, finds that the haematoporphyrin does not 
disappear when these articles of diet are withdrawn, and while 
admitting that the ingested haemoglobin and chlorophyll may possi- 
bly be converted, in part at least, into haematoporphyrin, he concludes 
that the greater portion is derived from human sources. On the 
whole, the evidence seems now in favor of the view that the haemato- 
porphyrin which is found both in the urine and in the feces originates 
within the liver, and is eliminated into the intestinal canal in the 
bile (see also Haematoporphyrinuria). 

PATHOLOGY OF THE FECES. 

General Characteristics. 

Number of Stools. — As has been pointed out (page 207), one or 
two stools in the twenty-four hours may be considered as normal. 
Individual peculiarities, however, must be taken into consideration. 

As the consistence of the stools is altered in diarrhoea, this condi- 
tion maybe defined as one in which too frequent and liquid passages 
occur, while the reverse holds good for constipation, the consistence 
of the stools in this condition being usually also altered. The term 
obstruction, on the other hand, denotes a state of affairs in which 
no stools are voided. In a general way it may be said that what- 
ever gives rise to increased peristalsis likewise produces diar- 
rhoea, and that whatever diminishes peristalsis gives rise to con- 

1 Stokvis, Nederl. Natuur-en Geneesknndig Congres, 1899, p. 378. 

2 Garrod, "The Urinary Pigments in their Pathological Aspects," Lancet, Nov. 10, 
1900. 

3 Saillet, Rev. de Med , 1896, vol. xvi. p. 542. 



222 THE FECES. 

stipation. In the former condition the number of stools may vary 
from one to thirty, forty, or even fifty in the twenty-four hours, 
as in Asiatic cholera. The consistence of the stool when only one 
is passed in the twenty-four hours will, of course, decide the ques- 
tion whether the case should be regarded as one of diarrhoea or not. 
One stool passed in the twenty-four hours may under certain condi- 
tions be regarded as a symptom of constipation, but more commonly 
this term is applied to a condition in which a stool occurs only every 
two, three, four, or more days. 

Consistence and Form. — The consistence of the stools may 
undergo variations, which run a course parallel to their number. 
They may be thin, mushy, and even watery. 

In constipation, on the other hand, owing to an increased absorp- 
tion of water, the feces may be passed as very hard and perfectly 
dry, roundish, scybalous masses, the rotundity of which is undoubt- 
edly referable to their long sojourn in the haustra of the colon. The 
individual scybala usually vary in size from that of a hazelnut to that 
of a walnut, and are frequently provided with one or two indenta- 
tions which, represent impressions of the taenia of the colon. Still 
smaller masses, closely resembling the dejecta of sheep, may also be 
seen. Their presence was formerly regarded as characteristic of 
stricture of the colon, but they are likewise found in ordinary cases 
of chronic constipation. Fecal ribbons and columns of the diame- 
ter of a pencil are found in cases of enterospasm of neurotic origin, 
as well as in stricture of the colon. 

Amount. — The absolute amount of feces voided in the twenty- 
four hours bears an inverse relation to the number of stools and their 
consistence, providing, of course, that no abnormally large ingestion 
of food has occurred. In that case an abnormally large stool of 
moderate firmness may be passed. Two exceptions must, however, 
be noted to this rule — i. e., the passage of large quantities of firm 
feces, following an attack of constipation of long duration or an 
attack of severe obstruction. 

Odor. — As the normal offensive odor of the feces is largely due to 
products of intestinal putrefaction, an increase in this respect will 
naturally be referable to conditions in which the putrefactive proc- 
esses are increased. A most disagreeable odor is thus met with in 
the so-called acholic stools. The odor of fatty acids is observed 
in the lighter grades of infantile diarrhoea, while a markedly putrid 
odor is associated with its severer forms. A very characteristic, 
sperm-like odor is further noted in the stools of cholera, owing to the 
presence of considerable quantities of cadaverin. A truly rotten 
stench is present in the gangrenous form of dysentery, and in car- 
cinomatous and syphilitic ulceration of the rectum. An ammoni- 
acal odor is due to an admixture of urine undergoing ammoniacal 
decomposition. 



PATHOLOGY OF THE FECES. 223 

Reaction. — The reaction of the stools La variable under patho- 
logical conditions, and is of no diagnostic importance. In typhoid 
fever, it is true, an alkaline reaction is so constantly met with that 
this symptom could possibly be of some value in doubtful eases. 

Unfortunately, however, it may also be neutral, amphoteric, and 
even acid. In acute infantile diarrhoea an acid reaction is the rule, 
but exceptions are also not infrequent. 

Color. — The color of the feces in disease may vary a great deal. 
When unaltered bile is present, the stools may assume a golden- 
yellow, a greenish-yellow, or even a green color. In cases of biliary 
obstruction or suppression, on the other hand, they become pasty 
and have a grayish or even a white color. This, however, is not so 
much due to the absence of coloring-matter derived from the bile, as 
to an insufficient absorption of flits, as was shown by Striimpell, who 
succeeded in obtaining stools of a light-brown color after feeding 
patients affected with catarrhal jaundice upon a diet containing 
minimal amounts of fat. Such acholic or colorless stools, as it would 
be better to say, are not only found associated with biliary obstruc- 
tion, however, but may also occur wheu the ducts are patent. They 
have thus been observed in various cases of leukaemia, carcinoma of 
the stomach or intestine, in simple infantile enteritis, chronic nephri- 
tis, chlorosis, scarlatina, tubercular enteritis, and especially frequently 
in debilitated consumptives and in cases of chronic tubercular peri- 
tonitis in children. In some of these conditions, as in tuberculosis 
of the intestines and of the peritoneum, the lack of color is probably 
due to a diminished absorption of fats. In others, however, this 
explanation does not hold good, as abnormally large amounts of fat 
are not necessarily present. In such cases the lack of color is prob- 
ably referable to the formation of colorless decomposition-products 
of bilirubin, such as the leuko-urobilin of Nencki, but nothing 
definite is known of the conditions which favor the formation of 
these products. In this connection it may be interesting to note 
that in those cases in which the biliary ducts are patent the color of 
the stools may vary not only from day to day, but even within the 
twenty-four hours. 1 A neurasthenic patient occurring in my prac- 
tice thus passed an acholic stool almost every morning and usually 
colored feces in the afternoon, for a period of several weeks. 

Generally speaking, the color of the stools becomes lighter the 
larger the number of movements, and vice versa. In Asiatic cholera 
and dysentery they may thus be colorless, while in severe constipa- 
tion the scybalous masses are almost black. 

If blood is present, the stools may present a scarlet-red, a dirty 

J Pel, Centralbl. f. klin. Med.. 1887, vol. viii. p.297. Le Nobel, Arch. f. klin. Med., 
1S8S, vol. xliii. p. 285. Vogel-Biedert, Lehrbncli der KJnderkrankheiten, 9th ed., 
1887, p. 115, Enke, Stuttgart. Berggriin u. Katz, Wien. klin. Woch., 1891, vol. iv. 
p. 858. 



224 THE FECES. 

brownish-red, a coffee, or even a perfectly black color. Adherent 
blood, usually bright red in color and found on scybalous masses, is 
probably always derived from the rectum or anus, while a change in 
color, indicating an earlier date of the bleeding, usually points to 
the colon. 

An intimate admixture of blood with the stool, the color being at 
the same time altered, so as to vary from a brownish red to black 
(owing to the presence of ferrous sulphide), is indicative of hemor- 
rhage into the stomach or the small intestine. The darker the color 
of the blood the more remote from the anus will be, as a rule, the 
seat of the hemorrhage. Black or coffee-colored stools are thus 
observed in cases of ulcer of the stomach or of the duodenum, in 
raelaena neonatorum, and similar conditions. 

When profuse intestinal hemorrhages take place, however, as in 
some cases of typhoid fever and nielama, and particularly when 
diarrhoea exists at the same time, the blood Avhich appears in the 
stools may be changed very little or not at all. 

While, as a rule, simple inspection or a microscopical examination 
of the feces will determine whether or not blood is present, it may 
at times be necessary to resort to more delicate tests, as the hemor- 
rhage may have been so slight as to escape detection with the naked 
eye, or so far removed from the anus that even blood-shadows can- 
not be found with the microscope. Hemorrhages of such trivial 
extent have been reported by Hasslin as occurring quite frequently 
in cases of chlorosis. This statement, however, I have not been 
able to confirm. If an investigation in this direction is to be made, 
the method of Miiller and Weber (see page 198), or that of Kor- 
czynski and Jaworski, should be employed. 

Korczynski and Jaworski's Test. — A small amount of the fecal 
material is treated with a pinch of potassium chlorate and a drop of 
concentrated hydrochloric acid. The mixture is carefully heated 
until it has become decolorized, more hydrochloric acid being added 
if necessary. The chlorine is then driven off, when one or two drops 
of a dilute solution of potassium ferrocyanide are added. In the 
presence of blood-coloring matter a distinct blue color is obtained, 
owing to the formation of Prussian blue. 

An admixture of pus in notable amounts also gives rise to a 
characteristic color, as is seen in cases of dysentery, syphilitic and 
carcinomatous ulceration of the colon and rectum, following the per- 
foration of a parametritic or periproctitic abscess into the rectum, etc. 

Carter and MacMunn l have recently pointed out that at times a 
chromogen may be present in the feces, which on exposure to the 
air is transformed into a red pigment, simulating blood-coloring 
matter. They report three cases in which this was observed. Mac- 
Munn expresses the opinion that the substance in question is closely 

1 Carter and MacMunn, Brit. Med. Jour., 1899. 



PATHOLOGY OF THE FECKS. 225 

related to stercobilin. The stools showed streaks of red upon the 
surface, and alter further exposure and repeated agitation turned a 
pronounced blood red throughout. 

Green stools are observed especially in infants, and may be refer- 
able to two different causes, being dependent on the one hand upon 
the presence of a bacillus, described by Le Sage, which produces a 
green coloring-matter, while on the other it may be referable to 
biliverdin. When green stools occur frequently, this condition is 
associated with the clinical symptoms of a severe cholera infantum. 
Such stools have also been noted in dysentery referable to an infec- 
tion with the Bacillus pyocyaneus. 

Quite characteristic also are the ipecacuanha stools, which closely 
resemble the so-called acholic stools. The green color produced by 
calomel, the yellow by santonin, rheum, and senna, the black by 
iron, manganese, and bismuth, have already been mentioned (see 
page 208). 

Macroscopical Constituents. 

Alimentary Constituents. — After having thus considered the 
number of stools, their consistence, reaction, odor, and color, it is 
necessary to look for gross admixtures, and especially for the presence 
of undigested food-material, such as pieces of meat, flakes of casein 
— this especially in the stools of children — and fragments of amyla- 
ceous food. The occurrence of such a condition, constituting what 
was formerly know T n as Uenterj/, is always indicative of disturbed 
intestinal or gastric digestion, or both. It is, hence, observed in 
cases of chronic intestinal catarrh, febrile dyspepsia, following the 
use of cathartics, etc. 

Occasionally also unaltered food in large amounts is found in the 
feces, owing to a direct communication between the stomach and the 
colon, as in cases of perforating ulcer or carcinoma of the stomach. 

When fat is present in abnormally large amounts it can usually be 
recognized with the naked eye. To this condition the term steatorrhoea 
has been applied (see page 223). In typical cases the fat is seen in 
the form of whitish or grayish masses, varying in size from that of a 
pea to that of a walnut, which are more or less intimately mixed with 
the fecal material, and may at first sight be mistaken for flakes of 
casein. From these, it may be distinguished, however, by its chem- 
ical reactions and its peculiarly glistening appearance. In other 
cases stools may be seen in which the fecal column is covered, to a 
greater or less extent, with a grayish, dense, asbestos-like substance, 
while the core itself presents the usual color. Nothnagel states that 
this appearance is referable to congealment of the fat, when it is 
exposed to a lower temperature than that of the body. I have re- 
peatedly observed this appearance, however, in stools which had just 
been voided and w T ere still warm. The passage of liquid oil in the 

15 



226 THE FECES. 

absence of fecal material has also been recorded, but it seems doubt- 
ful that the oil in such cases entered the body by the mouth. Fol- 
lowing the use of oil enemata such stools are, of course, seen. 

The elimination of abnormally large quantities of fat may be due 
to the ingestion of correspondingly large amounts. More frequently, 
however, it is referable to distinctly pathological conditions. A 
steatorrhcea will thus naturally occur when an insufficient supply 
of bile is poured into the small intestine, and hence is observed 
constantly in cases of biliary obstruction. In these cases, however, 
the microscope is usually necessary to demonstrate the presence of 
the abnormally large quantities of fat. True steatorrhcea, on the 
other hand, viz., the presence of fat recognizable with the naked 
eye, is more commonly met with in diseases affecting the resorptive 
power of the small intestine, such as extensive atrophy or amyloid 
degeneration of the intestinal mucosa, tubercular ulceration, etc., or 
in diseases involving the integrity of the lymphatic glands and vessels 
of the mesentery, as in chronic tubercular peritonitis, caseous degen- 
eration of the mesenteric glands, etc. In simple catarrhal condi- 
tions, however, steatorrhcea may also occur, and not only in infants, 
but, according to my experience, also in adults. The question 
whether or not steatorrhcea is constantly observed in cases of pan- 
creatic disease, as some observers have claimed, may now be answered 
in the negative, although it must be admitted that the two conditions 
are very frequently associated. Le Nobel, who has recently inves- 
tigated this subject, arrived at the conclusion that the steatorrhcea in 
itself is of little practical importance, but that its association with 
the absence of products of putrefaction from the stools, the absence 
of the salts of the fatty acids, and the presence of maltose in the 
urine, may possibly be regarded as indicating the existence of pan- 
creatic disease. 

Mucus and Mucous Cylinders. — So long as mucus occurs in 
small particles only, adherent to otherwise normal feces, it is of no 
pathological significance. Larger amounts are almost always indic- 
ative of a catarrhal condition of the colon or rectum, no matter 
whether the stool is otherwise normal or whether diarrhoea exists at 
the time. Peculiar formations are occasionally seen, viz., so-called 
mucous cylinders, which are passed in large or small fragments in a 
condition which has been described by Nothnagel as enteritis mem- 
branosa or colica mucosa. 1 Such masses, which at times measure a 
foot or more in length, are ribbon- or net-shaped, and are frequently 
passed in the absence of fecal matter, with severe tenesmus. They 
closely resemble Curschmann's spirals, but lack the central thread 
and the Charcot-Leyden crystals. They are probably indicative of 

1 Nothnagel, "Colica mucosa," Beitrage z. Physiol, u. Path. d. Darmes, 1884. 
Fleiner, Berlin, kiin. Woch., 1893, Nos. 3 and 4. Einhorn, Arch. f. Verdauungs- 
krank., vol. iv. p. 456. 



PATHOLOGY OF THE FECES. 227 

chronic constipation associated with catarrh of the colon. Not to 
be confounded with this condition is the passage of masses of mucus, 
which do nut present the cylindrical form, but which also may be 
passed with a great deal of tenesmus and in the absence of fecal 
matter ; this is very commonly seen in cases of nephroptosis asso- 
ciated with gastroptosis and enteroptosis. These formations are in 
all probability also referable to a catarrhal condition of the colon. 
In cholera Asiatica particles of mucus are seen which resemble 
grains of rice ; their presence was formerly regarded as characteristic 
of the disease ; but they are now known to occur in ordinary catar- 
rhal conditions also. 

Biliary and Intestinal Concretions. — Most important from a 
diagnostic standpoint is the examination of the feces for the presence 
of biliary concretions, which should never be neglected in cases of 
colicky abdominal pain of doubtful origin, whether associated with 
jaundice or not. 

When searching for gall-stones the feces should be stirred with 
water and passed through a fine sieve. Biliary concretions may then 
be found as small, crumbling masses or as hard stones presenting an 
irregular contour or the smooth, characteristic facets. In size they 
may vary from that of a millet-seed to that of a pigeon's egg ; large 
stones are rarely passed by the bowel unless perforation has occurred 
into the intestines and usually into the colon. 

Some calculi consist almost entirely of cholesterin, while others 
are composed essentially of inspissated bile, and still others of 
calcareous salts. The former are the most common, and are 
readily recognized by their softness and color, which may be white, 
grayish, bluish, or greenish. Their specific gravity is low T er than 
that of water. Very frequently they contain a nucleus, composed 
of earthy sulphates or phosphates. An analysis which I made of 
a stone of this kind, weighing 10.548 grammes, gave the following 
results : 

Cholesterin 72.590 per cent. 

Mineral salts 0.247 " 

Fats 5.090 " 

Biliary pigments 13.930 " 

Organic matter 7.270 " 

Calculi which consist largely of biliary pigments are brown in 
color. They are hard, and heavier than water. Frequently they 
contain traces of copper and zinc (Fig. 45). 

Calculi composed of calcareous salts generally present an irregular, 
roughened contour. 

Within recent years Welch has drawn attention to the not infre- 
quent presence of pure colonies of the Bacillus coli communis in gall- 
stones, apparently forming their nucleus. Typhoid bacilli also have 
since been observed in their interior, and it appears likely that the 



228 THE FECES. 

formation of gall-stones is primarily referable to an invasion of tfoe 
gall-bladder by such micro-organisms. 

Analysis of Gall-stones. — The stone is finely powdered and dried 
at a temperature of 100° C. It is then extracted with boiling water 
and the washings concentrated upon a water-bath to about 100 cc 
One portion of this amount is evaporated to dryness, and the soluble 
residue, as well as the mineral ash, determined after desiccation at a 
temperature of 105° C. The other portion is likewise evaporated 

Fig. 45. 

Off h 

2 - ' c \? 

Gall-stones. 
a, cholesterin ; b, pigment-stones. 

to dryness and extracted with alcohol containing a small amount of 
ether, sodium glycocholate being thus obtained. After treatment 
with hot water, as described, the substance is successively extracted 
with alcohol and ether. In the alcoholic extract fats and a small 
amount of cholesterin will be found. The greater portion of this 
is in the ethereal extract. The residue, which is insoluble in hot 
water, alcohol, and ether, is treated with a moderately strong solu- 
tion of hydrochloric acid, the earthy phosphates and oxides being 
thus obtained united to pigments. The bilirubin is removed by 
extracting with boiling chloroform. The pigments which are not 
dissolved in this manner are biliprasin, bilihumin, etc. 

Intestinal concretions (enteroliths ) are rare and usually come from 
the appendix. At times they contain some foreign body, such as a 
grape-seed, as a nucleus, upon which calcium and magnesium salts 
have become deposited. 

Fecal calculi or coprolith* are likewise only rarely seen. They 
represent inspissated fecal material which has become impregnated 
with lime and magnesium salts. More commonly they are found at 
the post-mortem table in the caecum, in the haustra of the colon, 
and in the rectum. 

Microscopical Examination. 

Technique. — In hospital work the stool should be passed into a 

well-warmed bed-pan and examined at once. This is particularly 

important in the search for amoebae. In private practice patients 

should be instructed to send their stools to the physician as soon as 

-ible, when suspicious-looking particles should be placed upon 



PATHOLOGY OF THE FECKS. 229 

the warm stage or examined upon a well-warmed slide. A very 
convenient form of warm stage, which may be obtained from instru- 
ment-makers at low eost, is composed of brass and made to be held 
in position on the stage of the microscope by spring clips. It is 
about 8 cm. long and 3 cm. broad, and has cemented to a recessed 
bottom an ordinary glass slip; an opening measuring 1.35 cm. in 
diameter is in the centre of the stage. To one of the long sides of 
the brass stage is fitted a projecting stem, about 10 cm. long, to 
which the heat of a spirit-lamp is applied. 

For ordinary purposes it is well to place the stool, if watery, 
in a conical glass, and to cover it with a layer of ether, so as to 
diminish the disagreeable odor. If mushy or firm, it should be 
spread upon a plate and covered with a layer of turpentine, or a 
5 per cent, solution of carbolic acid or thymol. 

Remnants of Food. — It has been pointed out that various micro- 
scopical remnants of food are observed in normal feces. In patho- 
logical conditions it is necessary to determine whether or not such 
remnants are present in abnormal amount, presupposing, of course, 
that excessive quantities of food have not been ingested. It is often 
possible to draw definite conclusions as to the state of intestinal 
digestion from the excess of one form of non-digested material over 
another. The presence of large quantities of undigested starch 
generally indicates a serious catarrhal condition of the small intes- 
tine, and it may, indeed, be said that the occurrence of more than 
mere traces of this material should always be regarded with suspi- 
cion. An increase in the number of muscle-fibers will likewise be 
observed under such conditions. 1 

The so-called acholic stools are usually very rich in fat, and par- 
ticularly so in cases of biliary obstruction associated with jaundice. 
At other times, however, the lack of color, as has been mentioned 
above, is not referable to the secretion of an insufficient amount of 
bile, but to the presence of colorless decomposition-products of 
bilirubin, such as the leuko-urobilin of Nencki. In these cases 
abnormally large quantities of fat are not always present. The 
conclusion that a stool contains excessive amounts of fat because 
it is apparently acholic is hence not justifiable unless a microscopical 
examination has been made. 

Leiner's Test for Casein. — Casein is most conveniently demon- 
strated with Leiner's method. To this end, a small amount of 
fecal matter is spread on a slide and dried in the air. It is then 
fixed by heat — passing the specimen through the flame of a Bunsen 
burner three or four times is sufficient — and stained with a mixture 
of equal parts of a 0.75 per cent, solution of acid fuchsin and 
methyl -green in 50 per cent, alcohol, the mixture being diluted ten 

1 A. Schmidt, "Die Klinische Bedeutung der Ausscheiduug von Fleischresten mit 
dem Stuhlgang," Deutsch. med. Woch., 1899, p. 811. 



230 THE FECES. 

times with water. After fifteen minutes the preparations are placed 
in distilled water and allowed to remain for one hour or longer. 
Casein and paracasein are thus stained a pale blue or violet, while 
similar bodies are practically all colored a light green, or more rarely 
a yellowish green. 

Epithelium. — Epithelial cells when present in large numbers 
always indicate an inflammatory condition of some portion of the 
intestinal tract. 

Cylindrical epithelial cells are found in abundance in all inflam- 
matory conditions affecting the intestinal mucosa. They are almost 
exclusively seen imbedded in mucus, and it is interesting to note that 
the cloudy appearance of the mucus is referable to the presence of 
these elements, and not to leucocytes, as is the case in the sputum. 
When bile-stained specimens are met with, the conclusion is justifi- 
able that the small intestine is involved. Degenerative forms are 
mostly seen ; well-preserved cylindrical or goblet-cells may, however, 
also be found, and are, according to my experience, much more com- 
mon than is generally supposed. 1 

Epithelioid cells may be found in carcinoma of the rectum. 

Red Blood-corpuscles. — Unaltered red blood-corpuscles, accord- 
ing to Xothnagel, are but rarely observed in the feces, no matter 
how intensely red they may be colored, providing that an ulcerative 
process affecting the colon or the rectum can be excluded ; in that 
case, as in the severer forms of dysentery, large numbers may be 
observed. If the hemorrhage has occurred higher up in the intes- 
tine, large and small masses of a brownish-red color are seen, which 
consist of hamiatoidin. They are mostly amorphous, but in some 
specimens the characteristic rhombic crystals may be observed. In 
general, it may be said that the higher the seat of the hemorrhage 
the darker will be the color of the pigment, and the less the chances 
of finding well-defined red corpuscles. In such cases recourse must 
be had to the hsemin test (page 41), to the iron test of Korczynski 
and Jaworski (page 224), or to Doncgany's test (page 430). 

Mucus. — Small hyaline particles of mucus, visible only with the 
microscope, are not infrequently met with under pathological condi- 
tions, and are of distinct diagnostic significance. T\ hen bile-stained, 
their presence is always indicative of disease of the small intestine 
proper, while colorless particles point to a catarrhal condition of the 
upper portion of the large intestine or the lower portion of the small 
intestine. Beginners should be careful not to mistake apparently 
hyaline particles of vegetable residue for mucus. Mucus never yields 
a blue color when treated with iodine, or iodine and sulphuric acid, 
and examination with a higher power will show the entire absence 
of any definite structure. Both forms, viz., colorless and colored 
particles, are found intimately mixed with the feces, and may be very 

1 Nothnagel, loc. cit. page 226. 



PATHOLOGY OF THE FECES. 231 

abundant. In addition to these forms Nothnagel has described the 
occasional occurrence of large numbers of roundish or irregular, 
very pale hyaline or opaque formations, which are devoid of all 
structure. Some specimens are homogeneous, while others present a 
distinct rimous appearance. They have thus far been found only in 
liquid stools, and are apparently of no diagnostic significance. To 
judge from their optic behavior, they probably consist of mucus. 1 

Leucocytes. — The presence of a large number of leucocytes usu- 
ally indicates a severe catarrhal, if not an ulcerative, condition of the 
intestines, the number of leucocytes or pus-corpuscles standing in a 
direct relation to the intensity of the inflammatory process. Pure 
pus in large amounts is observed especially in dysentery, and in 
cases in which accumulations of pus have perforated into the gut 
from adjacent organs or cavities. 

Crystals. — The crystals which may occur in the feces have already 
been briefly considered (page 210). Of these, the so-called Charcot- 
Leyden crystals deserve more detailed consideration. While occur- 
ring at times in normal stools, as also in those of typhoid fever, 
dysentery, and phthisis, such observations are rare. They appear to 
be quite constantly present, on the other hand, in cases of anchylo- 
stomiasis and anguilluliasis. They are also frequently associated with 
Ascaris lumbricoides, Oxyuris vermicularis, Taenia solium and sagi- 
nata. In cases of Trichocephalus they are but rarely seen, while they 
are always absent in the case of Taenia nana. These observations, 
made by Leichtenstern, are very important, and, according to the same 
observer, the occurrence of Charcot-Leyden crystals should always 
excite suspicion as to the existence of helminthiasis and lead to a 
careful examination of the feces for parasites or their ova. Their 
persistence in the feces after the evacuation of what would appear 
to be a complete taenia should be regarded as indicating the non- 
removal of the head. In amoebic colitis these crystals have also 
been observed by Lewis, Lafleur, Amberg, myself, and others. 2 

Animal Parasites. 
I. — Protozoa: 

Rhizopoda, 
Mori era. 

Amoebina, Amoeba coli. 
Flagellata s. mastigophora, 
Monadina, 

Cenomonadina, Cercomonas. 
Isomastigoda, 

Tetramitina, Trichomonas. 
Polymastigina, Megastoma entericum. 
Infusoria cilia ta s. vera, 

Holotricha, Balantidium coli. 
Gregarina s. sporozoa, 
Cocci di a. 

1 A. Schmidt, " Ueber Schleim im Stnhlgang," Zeit. f. klin. Med., vol. xxxii. p. 260. 

2 Leichtenstern, Deutsch. med. Woch., 1885, vol. xi. Nos. 29 and 30; Ibid., 1886, 
vol. xii. Nos. 11-14; Ibid., 1887, pp. 565,* 594, 620, 645, 669, 691, and 712. 



232 THE FECES. 

II. — Vermes: 

Platodes, 
Cestodes, 

Taenia saginata. 

Taenia solium. 
Taenia nana. 
Taenia diminuta. 

Taenia cueumerina. 
Bothriocephalus latus. 
Krabbea grandis. 
Trematodes, 

Distoma hepatieum. 
Distoma lanceolatiim. 
Distoma Buskii. 
Distoma sibiricum. 
Distoma spatulatum. 
Distoma conjunctum. 
Distoma heierophyes. 
Amphistoma hominis. 
Distoma haematobium. 
Distoma pulmonale. 
Annelides, 

Nematodes, 
Asearides. 

Ascaris lumbricoides. 
Ascaris ruystax. 
Ascaris maritima. 
Oxyuris vermieularis. 
Strongyloides, 

Anchylostomum duodenale. 
Trichotraehelides. 

Trichocephalus hominis. 
Trichina spiralis. 
Bhabdonema strongyloides, 
Anguillula intestinalis, 
HI. — Insecta : 

Piophila casei. 
Drosophila melanogastra. 
Homialomyia. 
Hyodrothcea meteorica. 
Cystoneura stabulans. 
Cal lip bora erythrocephala. 
Palleuria rudis. 
Lucilia caesar. 
Lucilia regina. 
Sarcophaga hfematoides. 
Eristalis arbustorum. 
Anthomyia. 

Protozoa. — The rhizopoda are essentially characterized by the fact 
that locomotion does not take place by the aid of independent organs, 
but by means of pseudopodia, viz., protoplasmic processes which the 
animal is capable of protruding from any portion of its body. Six 
orders have been described by zoologists, but only one, or possibly 
two, have thus fhr been found in the feces. 

Whether or not representative- of the monera occur in the feces of 
man is -till an open question. If so 3 they are apparently of no 
pathological significance. 1 

1 "Vothnasrel. loc. cit.. p. 110. Grassi. cited bv Bizzozero. v. Jaksch. WIen. klin. 
Woch.. 1888, vol. i. p. 511. 



PATHOLOGY OF THE FECES. 



233 



Of the amcebina, on the other hand, a most important member has 
been found, viz., the Amoeba eoli (Loach). 

The history of the discovery of this parasite and its relation to 
those severe forms of tropical dysentery and Liver-abscess which are 

met with also in our more temperate zones is of much interest, and 
at the same time illustrates the great importance which attaches to a 
systematic examination of the feces in all aggravated forms of diarrhoea. 
Amoeba coli (Loseh). — In 1875 Losch l discovered in the stools 
of dysenteric patients actively moving cell-like bodies of a roundish, 
pear-shaped, oval, or irregular form. He did not regard these as the 
cause of the disease, however, but looked upon them as only accident- 
ally present. Similar bodies were observed in Hong-Kong by Nor- 
mand iu cases of colitis ; and also by v. Jaksch. Sansiuo found 
them in a case in Cairo, and Koch in East Indian dysentery. It is 
interesting to note that Koch was the first to suspect the existence 
of a definite relation between dysentery and these organisms. Cun- 
ningham claims to have found amoebae frequently in the stools of 
cholera patients at Calcutta, and Grassi in normal stools, but espe- 

Fig. 46. 




Amoeba coli. 



cially abundant in cases of chronic diarrhoea. Whether all these 
observations are correct, and whether the organisms observed were 
identical in all cases, is, of course, difficult to say. So much is cer- 
tain, that the subject was still a very unsettled one when Kartnlis 2 
announced "that dysentery, and tropical liver-abscess associated 
with dysentery, are caused by the presence of the Amoeba coli," 
basing his conclusion upon an examination of five hundred eases. 

1 Loesch, " Massonbafte Entwickelung v. Amoben im Dickdarm," Vircbow's Arcbiv, 
vol. lvi. 

2 Kartulis, " Zur Aetiologie d. Dysenterie in Egypten,** etc., Vircbow's Arcbiv, 1885, 
vol. cv., and 1889, vol. cxviii. Centralbl. f. Bakt. u. Parasit., 1890, vol. vii. 



234 THE FECES. 

The fact that this parasite was absent in all other intestinal diseases, 
sneh as typhoid fever, intestinal tuberculosis, the ordinary forms of 
diarrhoea, etc., speaks strongly in favor of KartuhV view. 

In perfect accord with these observations are those made at the 
Johns Hopkins Hospital. 1 Osier- was the first in this country to 
demonstrate the presence of the Amoeba coli in a case of liver- 
abscess, both in the pus of the abscess and in the stools. Stengel, 
Musser, Dock, and others confirmed these observations, so that the 
pathogenic character of the Amoeba coli may now be regarded as an 
established fact. 3 This statement is based not only upon the few 
facts, more historical in character than otherwise, which have just 
been detailed, but rather upon the ensemble of collected data, among 
which the absence of micro-organisms other than the amoeba in the 
pus of the liver-abscesses, and the constant presence of the latter 
in such cases, rank among the most important. It is to be noted, 
however, that different forms of tropical dysentery exist, and that 
the Amoeba coli is essentially associated with the more chronic form, 
while the acute types are probably of bacillary origin (see Shiga's 
bacillus ). 

The size of the amoeba? varies from 10 fi to 20 u. "When at rest 
their outline is, as a rule, circular, occasionally ovoid ; but when in 
motion they present the extremely irregular contour of moving 
amoeboid bodies (Fig. 4(3). The protoplasm can be differentiated 
into a translucent, homogeneous ectosarc or mobile portion, and a 
granular endosarc, containing the nucleus, vacuoles, and granules. 
Within the endosarc the vacuoles constitute the most striking feat- 
ure. Sometimes the interior seems to be made up of a series of 
closely set clear vesicles of pretty uniform size. As a rule, one or 
two larger vacuoles are present, the edges of which are not infre- 
quently surrounded by fine dark granules. True contractile vesicles 
displaying rhythmic pulsations have not been observed, although the 
vacuoles may at times be seen to undergo changes in size. In some 
the Ducleus is quite distinct, while in others it may be altogether 
invisible. The protoplasm of the amcebae is strongly basophilic. 
The organism can be cultivated artificially on hay -infusion in the 
presence of bacteria (Miller). 4 

Most distinctive are the movements of these bodies. From any 
part of the surface a rounded, hemispherical knob will project, and 
with a rapid movement the process extends and the granules in the 
interior flow toward it. In these movements the clear ectosarc 
seems to play the most important part. 

1 Con ii oilman and Laflenr. " Amcebic Dysentery," Johns Hopkins Hosp. Rep., 1891. 
vol. ii. C. E. Simon. Johns Hopkins Hosp. Bull..* 1S90. 

2 Osier. Julius Hopkins Hosp. Bull.. 1-90. 

3 For the more recent literature see espeeiallv H. F. Harris. '* Amoebic Dysentery,*' 
Am. Jour. Med. Sci., 1898, p. 384. 

* C. O. Miller. "The Cultivation of Amoeba?." Contributions to the Science of Medi- 
cine, by the pupils of W. H. Welch, Baltimore, 1900, p. oil. 



PATHOLOGY OF THE FECES. 2-35 

In this connection I wish to refer to the occurrence of Laveran's 
Plasmodium malarias enclosed in red corpuscles, in the stools of cases 

of malarial colitis. In one case of chronic malarial intoxication 
with dysenteric symptoms the diagnosis was first made after an 
examination of the stools for amoebae ; these were absent, however, 
while a number of plasmodia could be demonstrated, pointing to 
the probable nature of the colitis. 

The Flagellata s. mastigophora differ from the rhizopoda in being 
provided with from one to eight flagella, which serve as organs of 
locomotion and possibly also for the apprehension of food-particles. 
Representatives of two orders only, viz., the monadina and isomasti- 
goda, have been found in the feces. Of the monadina in turn only 
one family, viz., the cenomonadina, and of the isomastigoda only 
two families, the tetramitina and polymastigina, are represented. 1 

The cenomonadina are small, oval, frequently elongated bodies, 
provided with one long flagellum at the anterior end, at the base of 
which food-vacuoles are situated. At the posterior end amoeboid 
movements may be observed, and there can be no doubt that the 
taking tip of food, to some extent at least, also occurs by the aid of 
pseudopodia. To this family belongs the cercomonas of Davaine 
and Lambl. The tetramitina are small, elongated bodies, provided 
with four flagella and a lateral, undulating membrane, which was 
formerly mistaken for a posteriorly directed flagellum. The tail- 
end of the organism tapers to a point. The nucleus is located at 
the base of the flagella. To this family belongs the parasite which 
was first discovered by Donne in the vagina, and which later was 
found also in the feces, and which has been variously designated as 
Trichomonas hominis, Cercomonas coli hominis, etc. 

The polymastigina are small, somewdiat oval bodies, provided with 
two or three flagella, situated either anteriorly or laterally — two or 
three on each side — while at the same time two additional flagella 
issue from the posterior end, which may either be rounded off or 
taper to a point. To this family belongs the Megastoma entericum 
of Grassi. 

Only three parasites belonging to the order of the flagellata have 
thus far been encountered in the human feces, viz., the Cercomonas 
hominis of Davaine and Lambl, the trichomonas of Donne, and the 
Megastoma entericum of Grassi. To judge from the earlier litera- 
ture upon the subject, many others have also been found, but more 
modern investigations have shown that they are in reality identical 
with the three just mentioned. The question whether or not these 
flagellate bodies are of pathological importance still remains sub 
judice. Apparently they are met with only in diseases associated 
with diarrhoea, and it appears that in some cases at least this is 

1 W. Janowski, " Ueber Flagellaten in d. menschlichen Fasces," etc., Zeit. f. klin. 
Med., vol. xxxi. p. 445. 



236 



'i i : 



directly dependent upon their presence; in otfaexs tlbe 
gained as though they z_-: r.~ _ intaioed an already existing diar- 
rhoea, referable to on-: :— while in a t hi rst dbss rf eases n© 
relation can be discovered between their presence and the disease in 
question. 

Cercomonas of DaTaine-LamM : «$»*, Ceneomonas lnominis (Dbr- 
vaine) ; monas (Marchand Monas lens (Grassi); M<«aas mono- 
nritina jbass The adult organise: --r Fig 47 :- ~:. :: 



_- : :- -' 




"-:■.' n zim 
, Cereomoxias of Daxafne, after JLenckart ; t, 
, oTdxnary forms • . ._ [ we31-ile«^lsqBeiiiarmB ; g, %, i. 
same. abortixe forms. 

ronndish in form, and provided anteriorly with ~ : — . :.' r _-.- 
Iran and posteriorly with a tail-like appendage. Its length varies 
from 0.005 to 0.014 mm. The younger forms ; . : - - >-_ : : - : ; - > '_ ; - - 
and sometimes irregular in outline ; the nagelliim is either absent 
or only rudimentary. 

Upon prolcr _ - : 

- - itsuagellum and n 
while vacuolation occurs 
death. 1 

Trichomonas, Donne : &yn., Trichomona ; . ..- I 
monas hominis (Grassi); monoeereomonas *m ss 
(Grassi); ProtorycoinT - rrinarius fO rm-mr .. zi 
Cercomonas coli hominis ('May ) ; Trichomonas imtestin 
and I. - tnonas « Bodo urinaria* (Kfn?;".e: 

. Tjertel.iahx.. 1359. x: ] 7: 

ISBt, Paris. Mart-baad. Tirebow's Arcbix. Ie75, xbL Isix. jl 293. I 
Axcb. f. pratt. Med., 1838 



atian it wlQ be seen that the 
ly protrude a protoplasm 
at the same time, indict 



-<-• Ti"»V| '.Jii 



i : . 1 - 



PATHOLOGY OF THE FECES. 



237 



(Fig. 48) is oval or spindle-shaped and measures from 0.012 to 0.03 
mm. in Length by 0.01 to 0.015 nun. in breadth. From its anterior 
pole tour flagella are given off, which are almost as long as the 
organism itself. From this point an undulating membrane extends 

laterally to the posterior pole, which may be rounded off or tapers to 
a tail-like appendage. This membrane is best seen when the move- 
ments of the flagella have ceased, as in specimens fixed in mercuric 
chloride solution (1 : 5000). The nucleus is situated at the base 
of the flagella, but is usually visible only in stained specimens 
(methyl ene-blue). At times the organisms may be observed to 

Fig. 48. 




Trichomonas intestinalis. 
a, a', c, trichomonas of the urine, after Marchand ; o, Trichomonas vaginalis, after Donne" ; 
b'. -:uw, after Scanzoni and Kolliker: d. Trichomonas intestinalis, after Piccardi ; e,e?,e?', 
same, amoeboid forms;/,/, trichomonas of the urine, after Dock. 



assume an amoeboid form ; the movements of the flagella have then 
ceased, and pseudopodia-like processes are protruded. The parasite 
i- identical with the trichomonas which has been found in the vagina 
and in the urine. 1 

Megastomaentericum,Gra— i : .*///?., Cercomonas intestinalis (Lambl); 
Megastoma intestinale (Biitschli); Lamblia intestinalis (Blanchard); 
Dimorphus muris (Grassi). The parasite (Fig. 49) is pear-shaped, 
and measures from 0.01 to 0.021 mm. in length by 0.0075 to <>.<>."> 
mm. in breadth. In its anterior portion a more or less well-marked 

1 Marchand, loc cit. Zunker, loc. cit., p. 236. Mosler u. Peiper, Nothnagel's Spec. 
Path. u. Therap., 1894, vol. vi. 



238 



THE FECES. 



depression can be made out, which constitutes the peristome or 
mouth-opening of the organism. It is provided with eight flagella, 
grouped in pairs. The first pair originates on the sides of the peri- 
stome and is directed backward. The second and third pair are 
situated somewhat posteriorly and are likewise directed backward, 
while the fourth pair issues from the tapering tail-end of the body. 
In fresh specimens the eighth flagella can usually not be made out, 
as the third and fourth pair are frequently agglutinated. The best 
results are obtained when the organism has been killed with mercuric 
chloride solution. The individual flagella vary from 0.009 to 0.014 

Fig. 49. 




Megastoma entericum. 
a, b, b', c, c', c", c"', various forms of Cercomonas intestinalis, after Lambl ; d, d' , encysted 
forms of Megastoma entericum, after Grassi and Schewlakoff ; e, Megastoma entericum, 
adult form. 



mm. in length. In the anterior portion of the peristome two round, 
hyaline bodies can be recognized, which represent nuclei. Vacuoles 
are absent, and nutrition occurs through osmosis, the parasite adher- 
ing to epithelial cells by its peristome. When treated with fixing 
solutions the chitinous envelope can be readily recognized. In the 
encysted form the organism is oval and measures from 0.007 to 0.1 
mm. in diameter. 

Grassi observed the organism in mice, rats, cats, dogs, rabbits, and 
sheep. 1 

1 Grassi u. Schewiakoff, Zeit. f. wiss. Zoologie, 1888, vol. xlvi. p. 143. 



PATHOLOGY OF THE FECES. 239 

Balantidium coli, Stein : syn. } Paramoecium eoli (Malmsten). The 
organism is oval and measures from 70// to 110//. in length by 
60 u to ~'l u in breadth. It is covered entirely with line, actively 
motile eilia, which are grouped most densely about the funnel-shaped 
mouth, while at the anus only a lew are seen. An ectosarc and an 
endosarc may be distinguished, and the parasite possesses the power 
to change its shape, and may appear quite round. In its interior 
we find a large, somewhat kidney -shaped nucleus, two contractile 
vesicles, and frequently fat-droplets, starch-grannies, etc. 

The parasite is pathogenic, but comparatively uncommon outside of 
Sweden and Filmland. Fifty-six cases of infection of the human 
being have thus far been reported (1901). Of these, twenty -one 
occurred iu Sweden and in Finnland, sixteen in Russia, three in 
Germany, five in Italy, one in the Sunda Islands, two in the United 
States, six in Cochin China, one in Africa, and one in the Philip- 
pines. Infection occurs through the dejecta of swine. 

Strong and Musgrave report that iu their case blood examination 
showed a relative increase of the eosinophiles. 

From 200 to 300 organisms have been encountered in a single 
drop of the liquid feces. 1 

The fourth class of protozoa, viz., the Gregarina or sporozoa, 2 is 
also said to be represented in the human feces. The coccidia and 
psorosperms belong to this order. They are oval bodies, measuring 
about 0.022 mm. in length, and contain in their ulterior a large 
number of small nuclei arranged in groups. They are entirely 
devoid of organs of locomotion, and obtain their nutriment by 
eudosmosis. Reproduction occurs in a common capsule, which 
bursts at a certain time and sends forth a whole generation of fully 
developed organisms. In human pathology they have become of 
interest in so far as certain observers have ascribed to them a role in 
the etiology of neoplasms. A disease of the liver analogous to the 
psorospermiasis of rabbits has also been described in man, and para- 
sites belonging to the same order have been observed in the skin. 

Vermes. — The class vermes has interested physicians since time 
immemorial, and is referred to in the writings of Hippocrates and 
others, special mention being made of the ascarides, called lumbrices, 
and the platodes, called lati. Speaking of the former, Lucas Tozzi, 
in 1686, says : "They find their way into the heart and its pericar- 
dium, into the brain, the lungs, the veins, and gall-bladder, where 
they are difficult to ' catch.' ' The same author, speaking of their 
effects upon the body, enumerates the following conditions as caused 
by their presence : epilepsy, vertigo, sopors, delirium, convulsions, 

1 Malmsten, Virchow's Archiv, 1897, vol. xii. p. .'50-2. Sievers, " OebeT Balantidinm 
Coli im menschlichen Dannkanal," Arch. f. Verdauungskrank., vol. v. p. 445. Ja- 
nowski, "Balantidium Coli." Zeit. f. klin. Med., vol. xxxii. p. 303. 

2 v. Wasielewski, Sporozoenkunde, 1896. 



240 



THE FECES. 



headache, syncope, palpitations, feelings of anxiety, cough, vomiting, 
nausea, diarrhoea, hiccough, prickling, borborygnii, erosions, tabes, 
acute and chronic fevers, and innumerable other maladies. 

It was even then deemed very important to make a diagnosis 
before the administration of an anthelmintic — a point which is well 

Fig. 50. 




Taenia saginata. 
a. natural size : b, head much enlarged ; c. ora much enlarged. 

to bear in mind at the present day. and the eggs, segments, or para- 
sites themselves should be sought for in every suspected case before 
treatment is begun. 

Taenia saginata, Goeze : $i/n., T. medi oca nel lata ( Kuchenmeister) ; 
T. incruris (Huber) ; T. dentata (Nicola). This parasite (Fig. 50) 



PATHOLOGY OF THE FECES. 



241 



is the most common tapeworm both in Europe and North America. 
EnfectioD occurs through the ingestion of measly beef. Its Length 

varies from 4 to 8 m. The head, which is devoid of a rostellum, 
is surrounded by tour pigmented suckers, each of which is encircled 
by a dark line. The individual segments are quite thick and opaque, 
and diminish in length as the head is approached, the largest measur- 
ing from 2 to 3 cm. They are each provided with a very much 
branched uterus, which opens laterally, the primary branches num- 
bering about twenty on each side. The ova are elliptical in form, 
of a brown color, and usually enclosed in a distinct vitelline mem- 
brane. Upon careful observation a double contour with delicate 
radiating stria^ can be discerned. In the interior the embryos are 
seen imbedded in a brown, granular material. 

The larval form of Taenia saginata, the so-called Cysticercus 
taeniae saginatae (Leuckart), or the Cysticercus bovis (Cobbold), has 
been encountered in cattle, the Rocky Mountain " antelope," the 
llama, and the giraffe. In the human being it has not as yet been 
observed. 1 

Taenia solium, Rudolphi : syn. y T. cucurbitina, plana, pellucita, 
Goeze. This parasite (Fig. 51) is far less common in this country than 

Fig. 51. 




Head of T. solium. X 45. (Leuckart.) 



the Taenia saginata, and may indeed be regarded as a curiosity. In 
Germany, also, it is only rarely met witib now, while formerly it 
was the most common tapeworm in that country. This change is 
undoubtedly owing to the fact that raw pork is now eaten less fre- 
quently. In Asia and Africa it is more common. 

Taenia solium is usually much shorter than Taenia saginata, rarely 
exceeding 3.5 m. in length. Most characteristic is the head, which 
is provided with four pigmented suckers and a rostellum, furnished 
with from twenty-four to twenty-six hooklets arranged in a double 
row. The mature segments measure from 1 to 1.5 cm. in length 

1 J. Ch. Huber, Die Darmcestoden des Menschen. Bibliograph. d. klin. Helminthol., 
Heft 3, Xo. 4, p. 69, Miinehen, 1892. It. Leuckart, Die Parasiten des Menschen, 
etc., 2d ed., 1880, Pt. 1. 

16 



242 THE FECES. 

by 6 to 7 mm. in breadth, and contain a litems which has only five 
to seven branches, thus differing greatly from that of Taenia =aginata. 
The ova are round, of a brownish color, and surrounded with a 
truck, radially striated membrane : in their interior the hooklets 
of the embryos can usually be made out. 

The larval form of this tapeworm, the Ci/sticercus cellulose?, has 
been found in swine, the wild boar, in monkeys, in the brown bear, 
in the dog, etc. At times, though rarely, an auto-infection with the 

_1< 'ttides of Ttenia solium has also been observed in the human 
being. Under such conditions the embryos of the wonn are set free 
in the stomach, and may then migrate into various parts of the 
body, where they become encysted. Most commonly the cysticerci 
are found in the skin : they have, however, also been observed in 
the heart, the lymph-glands, liver, bones, tongue, spinal canal, the 
brain, and the eyes. I have had occasion to observe a case of this 
kind at the Johns Hopkins Hospital (reported by Osier;. The 
patient, a laboring-nian. had never worked as a butcher or a cook, 
and never had a tapeworm. The cysticercus nodides. which were 
situated between the skin and the fascia, were very numerous, 
- -ruty-iive being counted on one day. One of these nodules was 
removed for examination, and was shown to be referable to the cysti- 
cercus of Taenia solium. The only subjective complaints in this case 
were pains and stiffness in the arms and legs. The individual cys- 
tic ereus was elliptical or roundish in form, measuring from 1 to 
10 mm. in diameter. In its interior the characteristic hooklets 
were seen. 1 

Tasrria nana, v. Siebold : syn. } hynienolepsis (Weinland). This 
parasite Fig. 52 has not been observed in America, but seems to 
be the most eonnnon tapeworm of Italy and Egypt. A few isolated 
cases have been reported in England and in Germany. It is found 
especially in young people, and often causes severe nervous symp- 
toms, such as convulsions, loss of consciousness, and even melan- 
cholia. It is only 8 to 25 mm. long and 0.5 mm. broad. The 
head is ball-shaped and provided with four suckers and a rostellum, 
bearing twenty-four to twenty -eight hooklets arranged in a siDgle 
row along its an: Ige. The individual segments are of a yel- 

lowish color and about four times as broad as long. The uterus is 
oblong and contains numerous ova, which are colorless, oval and 
surrounded by a distinct non-striated membrane. They measure 
from 0.8« mm. in size. In their interior the embryonic 

wonn. provided with live or six hooklets. may be distinguished. 
The number of worms which may at times be found in the digestive 
tract i- most astonishing, 5000 and even more having been counted 

1 Huber. loc. cit. Lenekart. loc. cit.. and Blanchard. Traite de Zoologie medicale, 
vol. i.. Paris. The Inspection of Meats for Parasites. Bull. No. 19. Bureau of Animal 
Industry. Washington. : - . - 



PATHOLOGY OF THE FECES. 



243 



on several occasions. The cystaeercua stage occurs in snails, which 
are frequently eaten raw in Egypt and Italy. 1 



Fig. 52. 






Taenia nana. Head, with rostellum drawn in ; proglottis ; egg. (v. Jaksch.) 



Tasnia diminuta, Ruclolphi : syn., Taenia flavapunctata (AVeinland) ; 
Taenia minima (Grassi) ; Taenia varerina (Parona) ; Taenia lepto- 
cephala (Creplin). Taenia diminuta was first described in man by 
Leidv, Grassi, and Parona. It measures 20 to 60 mm. in length, 
and is armed with two suckers, but is without a rostellum. The 
ova resemble those of Taenia solium. The cysticercus occurs in 
certain caterpillars and cocoons. In man it has been found in only 
six instances. 2 

Taenia cucumerina, Bloch : syn., Taenia canina (Linne) ; Taenia 
elliptica (Batsch) (Fig. 53). The parasite is found almost ex- 
clusively in children, the infection occurring through dogs and cats. 
Its length varies from 10 to 40 mm. The head is provided with 
about sixty hooklets, surrounding a rostellum in irregular rows. 
When this is visible it appears as a club-shaped protuberance. The 
ripe segments have a reddish color, and are very much longer than 
broad. The ova contain embryos already armed with booklets. 
The cysticercus occurs in fleas.'' 

Bothriocephalus latus, Bremser : syn,, Taenia lata (Linne*) ; 
Dibothrium latum (Rudolphi) (Figs. 54 and 55). This worm is 
5 to 10 m. long and of a reddish-gray color. Its head is shaped 
like a bean, and upon its flat surfaces two distinct grooves can be 
discerned, which probably act as suckers. The ripe segments are 
almost square in form, with the genital apparatus opening in the 
median line. The uterus presents four to six convolutions on each 



1 Grassi, Centralbl. f. Bakt. u. Parasit.. 1887, vol. i. p 
Ibid.. 1887. vol. ii. p. 282. Coinini, Ibid., p. 27. 



Grassi a. Oalandruccio, 
it)Ki.. p. '£(. Bilbarz, cited by Leuckart. 
'Leidy and Parona. cited by Leuckart 
:{ A. Hoffmann, Jahrb. f. Cinderheilk., 1887, vol. xxvi. Hefle 3 u. 4. Kriiger. St. 
Petersburg, med. Woch., 1887, vol. xii. p. 341. Brandt, Centralbl. f. Bakt. u. Parasit., 
1889, vol. v. p. 99. 



\U 



THZ fe:z: 



side. which become especially distinct when the segments are placed 
in water or exposed to the air. A rosette-lite appearance is then 
obtained, which is quite characteristic. The eggs are oval. 0.07 mm. 
lone and 0-045 mm. broad : they are enclosed in a brown envelope, 
at the anterior end of which a little lid can be recognized. Their 



Fig. 53. 



Fig. 54. 



M 



3k 



5w 






. , -T - 1 



Taenia eucumerina. Head : P- - unified. 

XSCE.) 



Peg \ ' 





Botnriocepb.alna. Head. 



Bothriocephalic; lanis. 



contents consist of protoplasmic spherules, all of about the same 
- . which are lighter in color in the centre than at the periphery. 
The larva? have been found in various fishes, such as the perch, 
the ling, the turbot. in various members of the trout family, but are 
most commonly encountered in the pike. It is thus readily under- 



PATHOLOGY OF THE FECES. 



245 



stood why the parasite is most common in lake regions, as in Switz- 
erland, northern Russia, southern Scandinavia, and northern Italy. 
Outside of Europe it is most common in Japan. In the United 

States it has been found in only a few imported eases. From a 
pathological standpoint it is of much interest, as it appears to stand 
in a causative relation to certain forms of severe anaemia. 1 

Krabbea grandis, Blanohard. This parasite has been observed in 
only one instance — in Japan. It is said to resemble certain bothrio- 
cephali which are found in seals. The genital organs are double in 
each segment. The vulva and uterus open ventrally. The worm 
attains a Length of 10 m. with a breadth of 2 cm. 

Trematodes. — The various forms of distoma which belong to this 
order are essentially hepatic parasites, and rarely occur in the feces. 

Distoma hepaticum, Abildgaard : syn., Fasciola hepatica (Linne) 
(Fig. 56). This, the most common liver-fluke, is 28 mm. long and 



Fig. 56. 



Fig. 57. 






Distoma hepaticum. (Leuckart.) 



Distoma lanceolatum (x 8) and eggs. (v. Jaksch.) 



12 mm. broad ; it is formed like a leaf. The leaf is provided with 
a sucker, and a second sucker may be found at its ventral surface. 
Between the two the genital opening is located, leading into a skein- 
shaped uterus. The eggs are oval, measuring 0.13 mm. in length 
and 0.08 mm. in breadth, the anterior end being provided with a lid ; 
their color is brown. In the United States the organism is practi- 
cally unknown, while in Germany it is most common in sheep. In 
the human being it is rare in both countries. It occurs in cattle, 
sheep, swine, cats, rabbits, etc. Infection occurs through a small 
snail, the Linnaeus minutus, which is found, in Germany especially, 
upon watercress. 2 

1 Schauman, Zur Kenntniss d. sogenannten Bothriocephalus-Anaemie, Berlin, 1894. 
Schauman a. Tallqvist, Uebex d. blutkorperchenauflosenden Eigenschaften d. breiten 
Bandwurms, Deutech. med. Woch., 1898, p. 312. Runeberg, Deutsch. Arch. f. klin. 
Med., 1SS7, vol. xli. p. 304. Askanazy, Z<-it. f. klin. Med., 1895, vol. xxvii. p. 4<>->. 

2 C. W. Stiles. Jour. Comp. Med. and Vet. Arch.. [894, vol. xv.. and 1895, vol. xvi. 
Huber, Trematoden. Bibliog. d. klin. Helminthol., Hefte 7 u. S, p. 283. 



THE 71.1. 

Distoma lane eola turn, Mphlis 3 has been found in only five 
_- : which irred in Germany F__ "" It is much smaller 
than Dist ms bepaticnni, measuring 8 : 9 mm. in length, hy _ 

mm. in breadth. It is lancet-shaped, tapering toward the head- 
end, but otherwise Jose - y resembles the above parasite. The ova 
are 0.04 mm. long ■. mm. broad, and contain fully developed 

embryos. In cattle, sheep, and hogs the organism is quite common. 1 

Distoma BusMi. Lane-aster: -?>;-.. Dist on: rhatonisii F 
I>:~: oma EaBanmn 7 isk The - urasite has Ben served in onlv 
three ses — in China It is much larger than the common liver- 
fluke. Infection probably - through certain fishes and orsf - 

Distoma sLbiricum. WioigT 3 .. EKstoma felinum (Rivolta). 

This pa::~:: - : and in Tomsk, " "Winigradotf. in eight autop- 
sies rf : me bandied and twenty-four. Ask:.: ey - : rts 
few ses : :..: " a from eastern Prussia, in which the eggs were 
found in th*r st< Is, In one of the cases, which canie to section, 
more than one hundred organisms were found in the biliary pass _ - 
Its length may reach 13 mm. The ova ax^ _ 3 m i. long 

and 10 i __ _m. broad. The inte~~ is -:mple and extends 

to tii | steri i -::-.-;--_.:— : the I : ty. I"- surface is smooth. 

Distoma spatnlatum. Leuekart : i .. Distoma endemicum : 7 
Dist ma Blanchard ; Distoma sinense I bbold . The 

habitat of die ._ oism is in cats. In the human being it has been 
-ly in Japan, where it ap: Ears t be quite common in 
certain localities. I: is at 11.75 mm. long and 2 i 2.75 mm. 
1. The living - > fa reddish color and translucen: a 

it is jssible to distinguish all its interior organs. Th 
mea~ are >.028 t mm. in length by )16 w 1 7 mm. in 

breadth loriess envelope. 4 

Distoma conjunctum, Cobbold. Distoma heterophyes, v. Siebold. and 
Amphistomnm hominis. Lewi- an M nell. are other paiasil - 
which have been bee aved in a : > ases, but are of little 

-:. The last named appears to be common in elephants. 

Distoma Baanatobium and Distoma pulmonale are described in the 
; 7 :oid the Sputum, respectively. 

.1 o. — The annelides are very common intestinal par 

and " : \ - 

As: = r.5 Jm:r.:::de5. Linne* Fig. M is the ylmdrieally shaped 
s in children and in the insane. The head 

consists : three projc : lips, which are provided with 

and - . The male meas pes a) a; 215 mm., the female a 

mm. in length. TL - 1 of the male is rolled up on its 

ventral surface like a hook, and is provided with papilla?. The gen- 

- 

bl. 1 Bakt. u. Para?:: 1SBG 
itei bv Braun. CentiaJbL I. Bakt. u. Parasit.. 1S&4. toL it. p. 602. 
* Blanchard. loc. cit. 



PATHOLOGY OF THE FECES. 



247 



ital aperture of* the female is situated directly behind the anterior 
third of the body. The eggs are yellowish brown in color, almost 
round, and measure 0.0b* mm. by 0.07 mm. in size ; they are sur- 
rounded by an irregular albuminous envelope, which is covered by 
a tough shell ; the contents are coarsely granular. 

Fig. 58. 




Ascaris lumbricoides. (v. Jaksch.) 

a. worm, half natural size ; b, head slightly magnified ; c, eggs. (Eye-piece I., objective 8 A, 

Keichert.) 

Ascaris lumbricoides is found in all countries, and also infests the 
pig and the ox. Its presence may occasion severe nervous symp- 
toms, but fortunately this is rarely the case. 1 

Ascaris mystax, Zeder : syn., Ascaris marginata (Rudolphi) ; 
Ascaris alata (Belli ngham) (Fig. 59). This worm is smaller and 
thinner than Ascaris lumbricoides, but otherwise very similar. The 
head is pointed and provided with wing-like projections, which con- 
stitute the main point of difference between the two. The male 
measures 45 to 60 mm. in length, the female 110 to 120 mm. Its 
ova are round, larger than those of Ascaris lumbricoides, and en- 
closed in a membrane which is covered with numerous small depres- 
sions. The worm is common in dogs and cats, but very rare in 
man. 2 



1 Lutz, Centralbl. f. Bakt. u. Parasit, 1838, vol. iii. pp. ",:;. .> i. t;if}. Hogg, Brit. Med. 
Jour., 1888, p. 121. Kartulis. Centralbl. f. Bakt. a. Parasit., vol. 1. p. 65. 

2 K. A. Rudolphi, Arch. f. Zool. u. Zoot., 1803, vol. iii. Pt. 2, p. 1. Idem, Entozoorum 
s. vermium intestinal, historia naturalis, Amstelaedaini. ii. 2. 



248 



THE FECES. 



Ascaris maritima, Leuckart, also belongs to this class. It has 
been observed in only one case — in Greenland. 

Oxyuris vermicularis, Bremser : syn., Ascaris vermicularis (Linne) ; 
Ascaris graecoram (Pallas) (Fig. 
60). The male is 4 mm., the 
female 10 mm. long. At the head 

Fig. 59. 



Fig. 60. 





Ascaris mystax. (v. Jaksch.) 
a, male ; b, female ; c, head ; d, egg. 



Oxyuris vermicularis. (v. Jaksch.) 
a, head; b, male ; c, female ; d, eggs. 



three lip-like projections with lateral articular thickenings may be 
seen. The tail of the male is provided with six pairs of papilla?, and 

Fig. 61. 




Anchylostomum duodenale. (v. Jaksch.^ 

a, male, natural size : b, female, natural size : c, male, magnified : d, female, magnified ; 

e, head (eye-piece II., objective C. Zeiss ; /, eggs. 

the female with two uteri. The eggs are 0.05 by 0.02 to 0.03mm. in 
size, and covered with a membrane showing a double or triple contour ; 
in the interior, which is coarsely granular, the embryos are contained. 



PATHOLOGY OF THE FECES. 



249 



Fig. 62. 



The female worm lives in the caecum, but after impregnation 
travels downward to the rectum. Here it causes most annoying 
symptoms, which are especially distressing at night, when the organ- 
ism emerges from the amis. In doubtful cases of pruritus ani ant 
vulvae an examination of the feces should he made for this parasite. 
The ova themselves do not occur in the feces. 1 

Anchylostomum duodenale (Dubini) : syn. } Anchylostoma duode- 
nale (Dubini) ; Strongylus quadridentatus (v. Siebold) ; Dochmius 
anchylostomum (Molin) ; Sclerastoma duodenale (Cobbold) ; Stron- 
gylus duodenalis (Schneider) ; Dochmius duodenalis (Leuckart) ; 
Uncinaria duodenalis (Roilliet) (Fig. 61). This organism belongs to 
the family Strongy hides, and is one of the most dangerous parasites 
met with in the human being. It has been found in Italy, Germany, 
Switzerland, Belgium, Egypt, and in the West Indies (Jamaica). 
Within recent years several cases have also been reported in the 
United States. From a pathological standpoint the parasite is of spe- 
cial interest, as its presence gives rise to severe and often fatal anremia. 
Griesiuger was the first to point out that the so-called Egyptian 
chlorosis is produced by this organism. In 
every case of severe ana3mia, particularly 
when occurring in patients who have 
been working in mines, tunnels and brick- 
yards, the feces should be carefully exam- 
ined for the ova of this parasite. The 
worm itself is rarely found. Its habitat 
is in the jejunum. Infection takes place 
through contaminated drinking-water, or 
possibly by direct transference of the em- 
bryos with dirty hands. 2 

The male is 6 to 11.5 mm. long, the 
female 10 to 18 mm. The head, which 
tapers somewhat, is turned toward the back ; 
the mouth capsule is hollowed out and sur- 
rounded by four teeth ; the tail of the male 
forms a three-lobed bursa, while that of the 
female tapers conically ; the genital opening 
is behind the middle of the body. Its eggs 
have an oval form and a smooth surface, 
measuring from 0.05 to 0.06 by 0.03 to 0.04 
mm. In their interior two or three segment- 
ing bodies are found, which rapidly develop outside of the human 
body, so that after twenty-four to forty-eight hours embryos may be 




Trichoeephalus dispar. 
IV. JAKSCH.) 

a, male, slightly magnified ; b, 
female, Blightly magnified; <\ 
ye-piece II., objective 8 
A, Reichert). 



1 Lutz. loc. cit. 

- Leichtenstern. Centralbl. f. klin. Med.. 1885, vol. vi. p. 10."); Deutsch. med. Woch., 
1885, vol. xi. ; 1886, vol. xii. ; 1—7. vol. xiii. Lutz. Volkmann's Sammlung, 188."), Nob. 
255 and 256. American cases : W. L. Blickhahn, Med. News, 1893, p. 662. F. S. Mohlau, 
Buffalo Med. and Surg. Jour.. 1895, p. 573. 



250 



THE FECES. 



found in the same feces in which the eggs were observed, or fully 
developed ova may be found after allowing the feces to stand for 
only a few hours. When allowed to dry, the young parasites become 
encysted, but after remaining so for from one to two weeks they are 
capable of infection. A second host for its cycle of development is, 
according to Leich tens tern, not necessary. 

Trichocephalus hominis, Schwank : syn., Trichocephalus dispar 
(Rudolphi) ; mastigodes (Zeder) ; trichuris (Buttner). This parasite, 
which belongs to the family Trichotrachelides, is formed like a whip, 






Fig. 63. 






-: 
'$ 



WBmsmA mafB 



'■: / / :\ ,'• 






W- 



■ if. 

•IS 






r 




mm 



- ■ . 

'■"■■■_.-. ■ r '. 



Ift 






Trichina spiralis in muscle. 



the last-end being the head-end, while the tail-end is very much 
thicker. The male measures 46 mm. and the female 50 mm. in 
length. The eggs are brownish in color, measuring 0.05 by 0.06 
mm. in size, and present a doubly contoured shell, with a de- 
pression at each end, closed by a lid. The contents are coarsely 
granular. The organism is said to be the most widely distributed 



PATHOLOGY OF THE FECES. 



251 



Fig. 64. 



intestinal parasite, occurring in Europe, North America, Asia, 
Africa, and Australia. Its habitat is in the caecum. The living 

worm is only rarely found in the feces. 1 

Trichina spiralis (Owen) (Fig. 63) is rarely found in the feces. 
The male measures 1.5 mm. in length, and is provided with four 
papillae between the conical lips. The female is 3 mm. long. The 
uterus is situated nearer the head 
than the ovary, which opens into it. 
Fertilization occurs in the intestinal 
canal. The eggs develop into em- 
byros in the uterus, emerge from 
this, and penetrate the intestinal 
walls, whence they are carried by 
the blood-current to the muscles. 
Trichinosis is far less common in 
the United States than in Europe. 2 
The diagnosis of sporadic cases has 
been greatly facilitated by the dis- 
covery of Brown that eosinophilia, 
often of high grade, is practically 
of constant occurrence during the 
acute stage of the disease (see page 
90). 

Anguillula intestinalis is 2.25 mm. 
long aud 0.04 mm. broad ; its mouth 
is three-cornered and bounded by 
three lips. The genital aperture 
is located between the middle and 
posterior third of the body. Its 
eggs are similar to those of Anchy- 
lostomutn duodenale, with which the 
anguillula is not infrequently asso- 
ciated ; but they are longer and more 
elliptical, with tapering poles ; they 
are never found in the feces unless 
active catharsis is established. Other- 
wise the embryos only are found, as 
the development of the ova occurs 
with great rapidity. When sexually mature, the parasite is called 
Anguillula stercoralis ; this again gives rise to embryos, which 
may in turn enter the intestinal canal. The Anguillula ster- 
coralis (Fig. 64) has a rounded body, which presents an indistinct 
cross-striation. Its head is like the top of a cane, and is provided 
with two lateral jaws, each of which is armed with two teeth. The 
male measures 0.08 mm., the female 1 .22 mm. in length. The patho- 

^rni, Berlin, klin. Woch., 1880. vol. xxiii. p. fil J. * Lcuokart, loc. cit., 




Anguillula stercoralis. (Bizzozero.) 



_ : - TEE FECES. 

logical significance of this parasite has not been definitely ascer- 
tained, but from its resemblance to Anchylostomum dnodenale it has 
become important from a diagnostic point of view. Some observers 
regard the parasite as harmless, while others, and notably Davaine, 
associate its presence with anaemia. 1 

Insecta. — As the larva? of the various insects met with in the 
feces have been very little studied, they will not be considered at 
this place ; they are apparently of no clinical importance. 

Vegetable Parasites. — Among the pathogenic vegetable parasites 
the bacillus of cholera, of typhoid fever, and of tuberculosis, as well 
as the bacilli of Booker, the Bacillus coli communis^ the Bacillus pyo- 
cyaneus, the Bacillus lactis aerogenes. the bacillus of Shiga, and the 
Proteus vulgaris, deserve especial consideration. 

The Comma-bacillus. — A^ early as 1848 certain "vibrios" were 
observed in abundance in the sfcc >ls of cholera patients by Yirehow, 
and in 1849 by Pouehet. Britton, and Swayne, no importance, how- 
ever, being attached to their presence at the time. 

The first accurate and detailed studies of the organism found in 
cholera stools were made in 1883 by the members of the French 
and German com mis-: his sent Ic Egypt to investigate the nature 
of the dreaded disease. The results of their work were first pub- 
lished by Koch in his report to the Berlin Sanitary Office in 1883, 
and in l v "- Steinss, Roox 3 y>card, and Thuillier. 

The clinical recognition of cholera Asiatica has now become a 
simple matter since Pfehfer lias demonstrated that the blood-serum 
of cholera patients ] assesses the property of causing arrest of 
motility and agglutination of the specific bacilli. Ordinary bouillon- 
cultures, however, can usually not be employed, as particles of the 
film when broken up may easily be mistaken for agglutinated 
bacilli. It is best in every case to make use of agar-cultures 
sixteen to twenty-four hours old, and to prepare emulsions in 
bouillon or normal salt solution as occasion requires. The emul- 
sion, moreover, should alway- ::; mined microscopically before 
nse, so as to insure the absence of any conglomerations of bacilli. 
The blood is then diluted in the proportion of 1 : 10 or 1 : 15. If the 
test-tube method is employed, the tubes should be kept in the incubator 
' . for only one or two hoars. Upon the slide the reaction is 
obtained in front five to twenty minutes. If no distinct agglutination 
is bs ed at the end of one hour, the diagnosis of cholera is rendered 
improbable. Dried blood retains its agglutinating properties for a 
considerable length of time, and may also be used for examination. 

The comma-baeillus is a slightly arched or half-moon-shaped 
little rod. and is somewhat shorter than the tubercle bacillus (Plate 

1 Grassi. Ontralbl. f. Bakt. u. P,r —" ii.p.413. Leichtenstern, Deutseh. 

med "" > - 11*. Per? h. p. L sri. metL, 1881 _•" 2. Compt. rend- 

de 1" Acad. .".-.- - 1882, 39 1 1- :^ier, Ibid., toL cxxi. p. 171. 



PLATE XII. 



FIG. 1. 

Spirillum of Asiatic Cholera. Impression Cover-slip from a Colony 
Thirty-four Hours Old. (Abbot! 



FIG. 2. 






54 



Bacillus of Fiiikler and Prior. (Cornil and Babes.; 



FIG. 3. 






teillus of Typhoid Fever from a Culture Twenty-four Hours Old., 
on Agar-agar. (Abbe:: 



PATHOLOGY OF THE FECES. 253 

XII., Fia;. 1). Occasionally two arc placed end to end with their 
convexities in opposite directions, thus presenting the appearance 

of the letter S. They are provided with flagella. Koch detected 
these bacilli in the intestinal contents and feces, but rarely in the 
vomited matter, in Asiatic cholera only. In the stools they at times 
occur in such numbers as to constitute pure cultures. In plate- 
cultures kept at a temperature of 22° C. white colonies with serrated 
borders may be observed after twenty-four hours. The color of 
such a colony is slightly yellow or rose red, its central portion gradu- 
ally assuming a deeper tint, and finally becoming liquefied. Upon 
agar-plates the bacilli form a grayish-yellow, irregular, slimy coat- 
ing, but do not liquefy the culture-medium. In stab-cultures, after 
twenty-four hours, a whitish color may be observed along the line 
of the stab ; around this there is formed a funnel-shaped depression, 
which gradually increases in size and apparently contains a bubble 
of gas. The upper portion of the culture-medium at the same time 
becomes liquefied, while the lower portion remains solid for days. 
In a suspended drop spirochretie-like spirals are observed at the 
margins, which often present as many as twenty distinct arches. 1 

Closely related to Koch's comma-bacillus, and possibly bearing 
to cholera nostras the same relation that the former bears to cholera 
Asiatica, is the bacillus of Finkler and Prior, discovered in 1884 and 
1885 (Plate XII., Fig. 2). This is, however, readily distinguished 
from the former by the following characteristics : it is larger and 
thicker than the comma-bacillus ; the colonies on gelatin plate- 
cultures show equally round and sharp-edged forms, which present 
a granular appearance under a low or medium power, and are usu- 
ally of a brown color. The organism liquefies gelatin very rapidly, 
a penetrating, excessively fetid odor being developed at the same 
time. In stab-cultures the bacillus of cholera Asiatica forms a 
funnel-shaped depression, while the bacillus of Finkler and Prior 
forms a stocking-like depression. 2 

In this connection the green bacillus of Le Sage, discovered in 
certain forms of infantile diarrhoea, must briefly be referred to, the 
stools, as has been mentioned, being of a grass-green color. The 
production of this pigment in cultures is one of the characteristics of 
the organism ; when injected into the intestines of animals it is said 
to produce diarrhoea and a catarrhal inflammation of the mucous 
membrane. 

Booker 3 has described nine different bacilli, as occurring in cases of 

1 R. Koch. Berlin, klin. Woch., 1884, vol. xxi. pp. 477,493, 509. 

2 Finkler, Deutsch. med. Woch., Tageblatt der Naturforscherversammlung, 1884, vol. 
x. p. 36, and 1885, p. 438. Finkler u. Prior, Erganzungshefte z. Centralbl. f. allg. 
Gesundheitspflege, 1885, vol. i. 

3 W. D. Booker. " A Bacteriological and Anatomical Study of the Summer Diarrhoeas 
of Infants." Johns Hopkins Hosp. Rep., vol. vi. 



254 TEE FECES. 

infantile diarrhcea. Seven of these closely resemble the Bacillus coli 
communis. Bacillus •'' A is a bacillus with rounded ends, measur- 
ing from 3 u to 4 a in length by 0.7 u in breadth. It is motile and 
liquefying. Colonies on agar and potato present a dirty-brown 
color. 

The typhoid bacillus, discovered by Eberth 1 in 1880 in the ab- 
dominal organs of patients dead with typhoid fever, is unfortunately 
not so readily recognized in the feces as the organisms just described. 
This is owing to the intimate relation which apparently exists be- 
tween the bacillus iu question and the Bacillus coli communis, with 
which it has many properties in common. A few years ago Eisner 
suggested a method which, it was hoped, would effectually overcome 
this difficulty, and in the hands of numerous observers good results 
were obtained. vYidal's agglutination test, however, which was 
almost simultaneously introduced, diverted attention from the study 
of the feces, and Eisner's work has practically been forgotten. 

In the meantime Widal's test has been carefully investigated, 
and although the reaction must unquestionably be considered as a 
specific reaction of typhoid fever, its value in diagnosis is neverthe- 
less limited (see page 100). As a consequence, further attempts 
have been made to discover a method which will enable the general 
practitioner to establish definitely the diagnosis of typhoid fever at 
an early stage of the disease. Whether or not Eisner's method 
(v. i.) has been deservedly abandoned, further investigations will 
show. At the present time another procedure, which was suggested 
by Piorkowski. is attracting widespread attention, as it is claimed 
that with this method the diagnosis can be made within twenty-four 
hours. 

Pioekowski's Method. 2 — The necessary culture-medium is pre- 
pared as follows : normal urine of a specific gravity of about 1.020 
is allowed to stand until the reaction has become alkaline ; it is then 
treated with O.o per cent, of peptone and 3.3 per cent, of gelatin. 
boiled for one hour, and filtered immediately into test-tubes with- 
out any further application of heat. The test-tubes are closed with 
cotton, sterilized for fifteen minutes in a steam sterilizer at 100° C, 
and resterilized after twenty-four hours for ten minutes. 

To examine the feces, one tube is inoculated with 2 cesen of the 
fecal matter, which should be as fresh as possible. From this tube 
4 cesen are transferred to a second tube, and a third is inoculated 
with from 6 to 8 ceesen from the one preceding. Plates are finally 
prepared and kept at a temperature of 22° C, as the presence of 
- -mall an amount of gelatin doe- not permit of exposure to higher 
temperatures. After sixteen to twenty-four hours an examination is 

1 Eberth. Virehow's Archiv. 1SS1. vol. lsxxiii. p. 486. 

2 Piorkowski. " Ein einfaches Verfahren z. Sieherstellung d. Typhusdiagnose.'' 
Berlin, klin. Woch., 1899. p. 145. 



PATHOLOGY OF THE FECES. 255 

made with a low power. At the expiration of this time the colonics 
of the colon bacillus appear as round, yellowish-brown, and finely 
granular specks, with well-defined borders, while the typhoid colo- 
nics show a peculiar flagellate appearance", from two to four fine 
colorless radicles usually starting from a light, highly refractive 
central focus. After forty-eight hours the radicles have greatly 
extended, and after forty-eight to fifty-six hours the colonies are 
perfectly developed and present a picture which strongly suggests the 
appearance of radishes, minute interweaving branches being given 
off in every direction, while uo difference can be observed at this 
time between typhoid and colon bacilli which have been grown for 
control in 10 per cent, normal or bouillon-gelatin. 

Piorkowski claims that he has thus been able to demonstrate the 
presence of typhoid bacilli in infected drinking-water, and in the 
feces of typhoid fever patients at a time when a positive result could 
not yet be obtained with WidaFs test. Recent reports bear out the 
claims of Piorkowski, and the method can hence be recommended in 
doubtful cases. 1 

Eisner's Method. 2 — The culture-medium is prepared as follows : 
an aqueous extract of potato (500 grammes to the liter) is treated 
with 10 per cent, of gelatin and boiled. The solution is then treated 
with 2.4 to 3.2 c.c. of a one-tenth normal solution of sodium 
hydrate, in order to secure the necessary degree of acidity, and then 
filtered and sterilized. 

When needed, a portion is placed in an Erlenmeyer flask and 
treated with 1 per cent, of potassium iodide. The mixture is inocu- 
lated with fecal material and the necessary plates prepared. Upon 
this medium only a few species of bacteria will grow, principally the 
Bacillus coli and the typhoid bacillus. After twenty-four hours the 
Bacillus coli colonies are already mature, while the typhoid colonies 
can scarcely be made out with a low power. After forty-eight hours, 
however, they appear as small, highly refractive, extremely fine, 
granular colonies, closely resembling drops of water, which can be 
readily distinguished from the large, much more granular, brownish 
colonies of the Bacterium coli. This difference is brought out par- 
ticularly well if diluted plates have been prepared. 

Brieger, 3 who carefully repeated the experiments of Eisner, states 
that typhoid bacilli are found in abundance in the stools so long 
as fever exists, but with approaching convalescence they diminish in 
number and ultimately disappear. If, notwithstanding the absence 
of fever, bacilli are found in notable numbers during convalescence, 
a relapse may be anticipated. 

In pure cultures the typhoid bacilli present the following features : 

1 A. Schiitze, "Ueber d. Nachweis v. Typhusbacillen in den Faeces," Zeit. f. klin. 
Med., vol. xxxviii. p. 39. 

a Eisner. Zeit. f. Hyg. u. Infektionskrank., 1895, vol. xxi. p. 25. 
3 Brieger, Deutsch. med. Woch., 1895, vol. xxi. p. 835. 



zi i ~"i- : m : ;•■•:.- : . :_ •" n-r-tui'L tii-E -"t^ : . i'ei 
. • » _- 3 ipns ar nmtfflmfflgafefflsnKii - -: .. ;• •„- 

: ; "tIIL,!: Tir : i: rag ^iteiihW: 

ut j - -:_:_-- -._-..: :v. :-:_ 7~_-~" _> . i 
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i kit- • - zj.e- '-.-i " l:':»t:l: lei - \_ - __i.._i-. 

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stab an: i \_- - be :. " t : : . . \ ■ n dl i : _ \ ~— 

sign? in iknx- ^iitatiio-i; e- •— :-_."-;;-- -._ - : rmti i : 
." .:" : ■"-:_"-: : ■ - entire zzx: :e:'.::»ri<e= tt~:' i: 

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..-. - k -- rii " ;..--■• - ^ -—-/-- : _- :- f 

_ c . ntrnatk i - 1 " mm . 

tofiaerctii;^^' pToxiaioi " " - . r : -~> -."-. -: m : _ : ■ 

;- . -- Ihz • ! •":.. ■ : - i inim? ' iz& j "-.- - "._- 
: \_<- 1 •■ i - " ■■;■-.: . - " " 

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fece? - lee :\ tec ""._•".-.• n ici-en ..i" - ■" ". ' :• - '"- •. "i 

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faimd in the |m m ■ ■■■• I pnniflait ~i-.-:t :. " | -:v- i ~ • _ - 
choliti- --- :■-- :..:v':. • -" : • - - ■ - "-- - 

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specks ^ th- , " 77m: ^ v_ =err£.ie: nri-a 

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fermentation take- 

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7' i . : - ." - maaan 



PATHOLOGY OF THE FECES. 257 

one of idiopathic bacteriuria. It is seen quite constantly in the 
stools of sucklings, but may also be met with in those of adults. 
It occurs in the form of rather stout rods, which frequently lie in 
pairs, resembling diplocooci. The organism is non-motile. Like 
the Bacillus eoli communis, it is decolorized by Gram 's method. In 
plate-cultures it forms a dense white film ; in stab-cultures a chain 
of white colonies resembling heads is Keen. In the latter, moreover, 
if the stab is closed, bubbles of gas will be seen to form, which 
rapidly increase in number and size. Milk is coagulated in large 
lumps in twenty-four hours ; at the same time, the formation of 
gas is much more intense than in the case of the Bacillus coli 
communis. 

The Bacillus pyocyaneus has within recent years beeu isolated from 
the stools of dysenteric patients, and has been proved the cause of 
several epidemics. The organism in question is a small motile bacil- 
lus measuring from 1 u to 2 /i in length by 0.3 p. to 0.5 ti in breadth. 
It sometimes occurs in short chains, but is usually single. It is 
stained with the common aniliu dyes, and is decolorized with Gram's 
method. It grows on the usual culture-media, and liquefies gelatiu. 
In 2 per cent, glucose-bouillou no fermentation takes place. Litmus- 
milk is curdled in about forty-eight hours. Some varieties produce 
indol. Most characteristic is the production of certain pigments, 
viz., pyocyanin and a fluorescent bluish-green pigment which is 
common to almost all varieties. 1 

Bacillus acidophilus, Moro. 2 This organism has recently been 
described by Moro as occurring in the stools of breast-fed infants, in 
which it normally prevails over all other forms ; under pathological 
conditions, on the other hand, as also in the stools of children, 
which have been fed with cows' milk their number is found dimin- 
ished, while the members of the coli-group enter into the foreground. 
Beyond the stools, the bacillus has been found in the outer portion 
of the secretory duct of the human mammary gland, in the milk, 
and the skin of the nipple and its immediate surroundings. It is 
apparently not pathogenic. 

The organism occurs in the fjrm of slight rods measuring 1.5 u 
to 2 ii in length, by 0.6 fi to 0.9 a in breadth. It is non-motile. 
It is not decolorized by Gram's method, but lose- this property after 
from thirty-six hours to nine days. The best growths are obtained 
on beer wort bouillon and common bouillon when acidified with a 
mineral acid ; the acidity of 10 c. c. of the medium may correspond 
to 10 c.c. of a decinormal solution of potassium hydrate. The 
optimum temperature is 37° C; between 20° C. and 22° C. no 

1 A. J. Lartigau, "A Contribution to the Study of the Pathogenesis of the Bacillus 
Pyocyaneus," etc.. Jour. Exper. Med., 1898, No.*6. 

2 Moro, " Ein Beitrag zur Kenntniss der normaleu Darmbacterien des Sanglings," 
Jahrbuch f. Xinderheilk., vol. Hi. Also: "Ueber die aacb Gram farbbaren Bacillen 
d. Siiuglingstuhles," Wieu. klin. Woch.. 1900. No. •">. 

17 



258 THE FECES. 

growth occurs. On the various agar-slants imperfect development 
takes place ; on potato the organism does not grow. It is an active 
acid-producer, but does not give rise to the formation of gas ; with 
Escherich's stain it is colored blue. 

Esckerich's Stain. — This stain is now extensively used by podiat- 
rists in order to ascertain any deviations from the normal in the flora 
of the feces. Under strictly normal conditions the bacilli which are 
found in the stools of breast-fed children are thus nearly all colored 
blue (see above), while red bacilli are but little numerous. In the 
case of infants, on the other hand, which are fed exclusively on cows' 
milk the red bacilli predominate, while in mixed feeding the blue 
enter into the foreground in about the proportion in which breast- 
milk is employed. The red bacilli belong to the coli-group. These 
further predominate, or may be found exclusively, if for any reason 
intestinal digestion is impaired. Staphylococci, streptococci, etc., 
when simultaneously present, are in either event staiued blue. In 
staphylococcus enteritis the blue bacilli which normally exist in the 
stools of breast-fed infants are almost entirely replaced by staphylo- 
cocci. At the beginning of the euteritis they are not numerous, but 
they increase during the progress of the disease, and finally disappear 
when the child recovers. 

In staining, the following solutions are employed : 

1. An aqueous solution of gentian- violet (5 : 200). This is boiled 
for one-half hour and is then filtered ; it keeps for a long time. 

2. A mixture containing 11 parts of absolute alcohol and 3 parts 
of oil of anilin. 

(1) and (2) are mixed in the proportion of 8.5 : 1.5 ; the resulting 
solution keeps for from two to three weeks, but not longer. 

3. A solution of iodo-potassic iodide coutaining 1 part of iodine 
and 2 parts of potassium iodide in 60 parts of water. 

4. A mixture of equal parts of oil of anilin and xylol. 

5. A concentrated alcoholic solution of fuchsin, diluted with an 
equal volume of absolute alcohol. 

A bit of the stool is spread upon a slide in as thin a layer, as 
possible. After drying in the air the specimen is fixed by passing 
through the flame of a Bunsen burner. It is then stained for a few 
seconds with the mixture of (1) and (2), blotted, placed in the 
iodine solution for a few seconds, blotted again, decolorized with (4) 
until a notable extraction of color no longer occurs. It is washed 
with xylol, dried, and finally stained for a few seconds with the 
fuchsin solution, washed with water, blotted, and is then ready for 
examination. 1 

Proteus vulgaris, Hauser. This organism, while usually regarded 
as non-pathogenic, should be numbered among the bacteria which 
inav at times develop pathogenic properties. Baginsky and Booker 

1 Moro. loc. cit. 



PATHOLOGY OF THE FECES. k 259 

have frequently found it in the stools in eases of infantile summer 
diarrhoea. Escherich observed it at times in the meconium. 

Brudzinski examined the dyspeptic and fetid stools of a number 

of artificially i'vd infants in Escnerich's clinic, and in all the eases 
found the proteus. Others have encountered it in inflammatory 
conditions of exposed surfaces, in appendicitis, in perforative peri- 
tonitis, and even in closed abscesses, either alone or in association 
with other bacteria (Welch). A mixed infection with the proteus 
and LofHer's bacillus has also been observed. The organism forms 
little rods, measuring about 0.(3 it in diameter, while their length is 
variable; at times a more roundish form is observed ; at others little 
rods measuring from 1.25 ft to 3.75 t a in length, or even long 
threads. They are readily stained, but are easily decolorized by 
alcohol or Gram's method. Most characteristic is their growth upon 
nutrient gelatin. At the temperature of the room little depressions will 
be observed after six to eight hours, which are surrounded by a narrow 
zone of bacilli from which a thin, wide film, provided with irregular 
projections, extends over the culture-medium. From this film 
islets become separated, which slowly extend over the gelatin and 
cause its liquefaction. The organism is motile. It decomposes 
urea and causes albuminous putrefaction. The nitroso-indol reaction 
is readily obtained in bouillon-cultures. 1 In boiled milk the organ- 
ism grows well, while in fresh milk it develops only irregularly, and 
in acid milk no growth takes place at all. 

Bacillus dysenteriae, Shiga. This organism is now regarded as 
the specific cause of one form of dysentery which prevails in the 
tropics. It was discovered by Shiga in Japan (1897), and has since 
been encountered, by Flexner and Strong more especially, in the 
acute form of the disease which prevails in the Philippine Islands 
and in Porto Rico. In some of the cases amoebae also were found, 
but they are rarely numerous. The stools at first contain a small 
amount of mucus; this rapidly increases and soon becomes blood- 
streaked. Generally within forty-eight hours, or a shorter time, the 
stools consist of nothing but reddish, bloody mucus, and on micro- 
scopical examination red blood-corpuscles, leucocytes, and epithelial 
eolls are found. 

The bacillus in question Shiga describes as a short rod with 
rounded ends, much resembling the bacillus of typhoid fever, or the 
greater portion of the cdi-group. It is possessed of moderate 
motility, but flagella have not as yet been demonstrated ; neither has 
spore-formation been observed. The organism decolorizes by Gram's 
stain. 

Upon gelatin plates at room temperature there appear, after a few 
days, small round dots, which, magnified under l<>w powers, are 
slightly yellow and finely granular. After a few days they increase 

1 Fliigge, loc. cit. 



260 THE FECES. 

in size ; the middle portion of the colonies then appears darker under 
a low power, while the outer zone appears brighter and more seed-like. 
The superficial and deeper colonies show no marked variation. In 
stab-cultures of gelatin a whitish strand forms the whole length of 
the stab. The gelatin is not liquefied. 

After twenty-four hours in the incubator single colonies upon 
slanted agar appear moist, bluish, and partially translucent. After 
two days they present a combination of a middle dark and a periph- 
eral bright, sharply defined zone. 

The growth on glycerin-agar is slightly more abundant than on 
ordinary agar. The organism grows on blood-serum without lique- 
fying it. 

In the stab-cultures of glucose-agar there is formed along the 
whole line of the puncture a thick gray-white strand without the 
development of gas. Upon potato after twenty-four hours in the 
incubator there is hardly any perceptible growth, only the surface 
appears slightly shiny. After two days this changes to a yellow 
brown. In the course of a week the growth is heavier and of a 
deeper brown color. Bouillon cultures show after a day in the 
incubator a somewhat intense cloudiness, with a moderate precipitate. 
]S"o pellicle is formed on the surface. Xo indol reaction is present. 
Litmus-milk after twenty -four hours appears reddish ; otherwise, 
however, it undergoes no change. The milk never coagulates. 

The bacillus is pathogenic for mice, rabbits, and guinea-pigs. 
It is agglutinated by the patient's blood-serum, and it is interesting 
to note that this reaction is obtained only with cases definitely known 
to have been infected with the micro-organism in question. In 
several cases of amcebic dysentery, which were examined in this 
direction at the Johns Hopkins Hospital, the blood-serum failed to 
produce the reaction with the bacillus obtained at Manila. As 
Flexner states, these results tend to emphasize the distinction of 
types of dysentery occurring in the tropics. 1 

CHEMISTRY OF THE FECES. 

According to Hoppe-Seyler, mucin is a constant constituent of the 
feces, both under physiological and pathological conditions, for- 
mally, however, it is never possible to recognize its presence either 
with the naked eye or with the microscope. In order to demonstrate 
the presence of mucin in the feces they are digested with water and 
treated with an equal volume of milk of lime ; the mixture is 
allowed to stand for several hours, when it is filtered and the filtrate 

1 K. Shiga. Centralbl. f. Bakt.. Parasit. u. Infectionskrankh., 1898, vol. xxiv. E. P. 
Strong and Musgrave. " Preliminary Xote regarding the ^Etiology of the Dysenteries 
of Manila.'' Eeport of the Surgeon-General of the Array, Washington. 1900, p. 251. 
S. Flexner. "On the Etiologv of Tropical Dvsenterv." Bull. Johns Hopkins Hosp.. 
1900. p. 231. 



CHEMISTRY OF THE FECES. 261 

tested with acetic acid. In the presence of mucin a cloud develops 

upon addition of the acid. 

Albumin is demonstrated in the feces by treating them repeatedly 
with water slightly acidified with acetic acid. The filtrate is then 
examined for albumin according to methods given elsewhere (see 
Urine). Under normal conditions these reactions prove negative. 
Pathologically, serum-albuniin has been observed in cases of typhoid 
fever and chlorosis. 

Peptones (albumoses) are normally absent from the feces. They 
have been observed in typhoid fever, dysentery, tubercular ulcera- 
tion, purulent peritonitis with perforation into the gut, atrophic 
cirrhosis, and carcinoma of the liver. Acholic stools are also usually 
rich in peptones. 

The peptones are demonstrated in the following manner : the 
feces are digested with water, so as to form a thin mush ; they are 
then boiled, filtered while hot, and the filtrate examined for albumin, 
so as to be sure that all of this has been removed. The mucin is 
removed by treating with lead acetate, when the filtrate is examined 
for peptones as described in the chapter on Urine (which see). 

Of the carbohydrates, starch, glucose, and certain gums may 
be found. In order to demonstrate these the feces are boiled with 
water, filtered, and evaporated to a small volume. This solution 
may now be tested with phenylhydrazin or Trommer's reagent for 
glucose (see Urine), and with a solution of iodo-potassic iodide 
for starch (see Saliva, page 139). The residue is extracted with 
alcohol and ether, as described under the heading of fatty acids, 
and then with water. The nitrate of the aqueous extract is con- 
centrated, boiled with dilute sulphuric acid, and then over-saturated 
with sodium hydrate. This mixture is treated with cupric sulphate 
and boiled, in order to test for dextrin and gums. 

Bile-pigment, which is normally absent from the feces, occurs in 
large amounts in catarrhal conditions of the small intestine, and may 
be demonstrated by Gmelin's method, viz., a drop of the filtered 
liquid, or a particle of highly colored fecal matter, is brought into 
contact with a drop of fuming nitric acid, when the yellow color will 
be seen to pass through the various shades of the spectrum, the 
green shade being the most characteristic. At times, however, it is 
not possible to obtain a positive reaction in this manner, although 
bile-pigment is present. In such cases the examination should be 
conducted under the microscope, and attention directed to bile-stained 
epithelial cells, leucocytes, particles of mucus, and crystals. 

Whenever there is increased intestinal putrefaction the fatty acids, 
phenol, indol, and skatol will, of course, be found in increased 
amounts. 1 

1 A. E. Austin, "The Chemical Examination of the Feces for Clinical Purposes," 
Phila. Med. Jour., 1900, p. 551. 



262 THE FECES. 

Ptomains. — Of ptoroains, only two have been isolated from the 
feces, under pathological conditions, viz., putrescin and ca da verm. 
They have been found in Asiatic cholera, in cholerina. dysentery, 
and in connection with cystinuria. In cholera and eystinuria their 
amount may be quite large. Baumann and v. Udranszkv thus 
obtained 0.5 gramme of the benzoylated compounds from the col- 
lected feces of twenty-four hours. In cholera the cadaverin seems 
to predominate, while in cystinuria more putrescin is found. 1 

To isolate the diamins in question, the feces are digested with 
alcohol which has been acidified with sulphuric acid. The alcoholic 
extract is evaporated, the residue dissolved in water, and further 
benzoylated, as described in the section on Urine. 

THE FECES IN VARIOUS DISEASES OF THE 
INTESTINAL TRACT. 

Acute Intestinal Catarrh. — This condition follows the ingestion 
of excessive quantities of normal food, of tainted food (meat, fish, 
cheese, etc.), beer, and of certain poisons, such as acids, alkalies, 
arsenic, corrosive sublimate, etc., when taken in toxic quantities. 
It is also observed as the result of a general infection, as in summer 
diarrhcea, cholera nostras, typhoid fever, and severe malaria, and is 
associated with disturbed circulatory conditions, producing a passive 
hyperemia of the gastro-intestinal mucosa, as in diseases of the liver 
and portal system, in chronic heart and lung diseases, etc. How far 
these circulatory disturbances may be considered as primary causes 
remains to be seen. Possibly they merely act as predisposiDg causes 
of certain chemical processes taking place in the intestinal contents. 

The stools are usually increased in number in proportion to the 
degree in which the large intestine is affected. Two or three, or ten 
or more, stools may be passed within the twenty-four hours. In 
consistence they are mushy or even watery, containing in some cases 
90 or 95 per cent. Their color is usually light yellow, but may, at 
times, be green. Microscopically, remnants of food may be found 
in large quantities, as also numerous bacteria, triple phosphates, 
isolated pus-corpuscles, and desquamated cylindrical epithelial cells. 

A duodenal catarrh can only be diagnosed when icterus exists at 
the same time. 

In catarrh of the jejunum and ileum, when the large intestine is 
not affected, the stools are firm, formed, and speckled with small 
hyaline particles of mucus, which are visible only with the micro- 
scope. Usually, however, the large intestine also is affected, when 
the stools are loose and contain undigested particles of food, the 
latter indicating abnormal conditions in the small intestine. Bile- 

1 C. E. Simon, '"Cystinuria and its Eelation to Diaminuria.'* Am. Jour. Med. Sci., 
Jan., 1900. 



THE FECES IN DISEASES OF THE INTESTINAL TRACT. 263 

pigment is also met with, as the contents of the small intestine only 
give Gmelin's reaction. 

Catarrh of the large intestine probably always exists whenever 
diarrhoea occurs. 

When the colon is extensively affected mucus appears in larger 
masses than otherwise ; and if the catarrh is very low down the 
feces may be formed, but are covered with mucus. 

Chronic Intestinal Catarrh. — This may follow an acute attack, 
and may also occur after dysentery, severe malaria, typhoid fever, 
etc. Diarrhoea usually alternates with constipation. It is not very 

Fig. 65. 



' ■ -~"* '.-'....... ''•{''.' ■•:/':• : i : - '■■;':■ ,r'/"^^ : W- '„•. • :'. ''■ 



Rectal discharge from a case of enteritis membranosa. 

common in adults, while in children it is quite frequently observed. 
Macroscopically and microscopically it presents the same picture as 
in the acute form. 

Enteritis membranosa is a form of chronic intestinal catarrh which 
is essentially characterized by the evacuation of cylindrical masses 
of mucus, as described on page 226 (Fig. 65). 

Cholera Nostras. — This is an infectious disease affecting both 
stomach and intestines, and is probably dependent upon the pres- 
ence of the bacillus of Finkler and Prior. 

The stools are first feculent, but soon become colorless and more 
and more watery, until they ultimately resemble the so-called rice- 
water stools of cholera Asiatica, and contain much serum-albumin 
and mucin. 

Summer Diarrhoea of Infants. — Tn this disease six or seven 
stools are passed daily, which are more liquid than normally, of a 
fetid odor, and contain Makes of casein. They are often green when 
passed, or may assume that color on standing. Mucus is present, 
and when the colon is especially affected may occur in Bago-like par- 
ticles. Piis-corpuscles; epithelial cells, and small amounts of blood 
may be present in severe forms. 

Booker, in his classical work on the summer diarrhoea of infants, 
arrives at the conclusion that the disease should not be attrib- 



264 THE FECES. 

uted to the presence of any particular micro-organism, but that 
the "affection is the result of the activity of a number of varie- 
ties of bacteria, some of which belong to well-known species and 
are of ordinary occurrence and wide distribution, the most impor- 
tant being the streptococcus and Proteus vulgaris." He also found 
that in the colon the Bacillus lactis aerogenes occurs in greater num- 
ber than in the normal intestine, and that it may even predominate 
over the Bacillus coli communis. Among other forms of bacteria 
which occur frequently and in great abundance are small, short, 
faintly staining bacilli ; long, very slender bacilli ; large bacilli with 
pointed ends, and small, faintly staining spirilla. 

Dysentery. — This is an infectious disease, and may be caused 
by several varieties of bacteria, such as the bacillus of Shiga, the 
Bacillus pyocyaneus, and others. The stools during the first few days 
are irregular. A moderate diarrhoea then sets in ; the stools are thin, 
but still feculent, and number five or six per diem. After several 
days the diarrhoea increases and the stools assume a definite char- 
acter, numbering from ten to twenty or even fifty or sixty in the 
twenty-four hours. At the same time they become scanty in amount, 
usually not exceeding 10 or 15 grammes at a time. They are now 
sero-sanguineous in character, and in them may be found pieces 
of necrotic tissue. Microscopically, blood-corpuscles, particles of 
mucus, pus-corpuscles, and numerous bacteria are seen. According 
to the preponderance of blood, pus, mucus, etc., the stools are termed 
sanguineous, sero-sanguineous, putrid, mucoid, etc. Shreds of mucus, 
resembling frogs' eggs or kernels of tapioca, which are, in all proba- 
bility, casts of follicles, are also found. Typical dysenteric stools 
do not, as a rule, emit a marked odor, but those of the gangrenous 
form are very offensive. 

Amoebic Dysentery. — This form of dysentery is especially inter- 
esting, not so much on account of its prevalence, however, as from the 
importance attaching to an early diagnosis, since successful treatment 
is altogether dependent thereupon, and differs materially from that 
employed in other forms. 

The number of stools may vary within very wide limits — from 
six to twenty or even thirty in the twenty-four hours. They may 
be wholly mucoid, streaked here and there with pus, and presenting 
a few grayish threads. Others seem to be made up of a greenish, 
pultaceous mass, in which at times large greenish, irregular sloughs 
are observed. Such stools are usually slight in amount. Occasion- 
ally large brownish liquid evacuations are seen, in which small 
grayish-white masses occur, imbedded in blood-stained mucus. Such 
stools contain the diagnostic amoebae most abundantly. 

For a satisfactory examination the bed-pan should be well warmed 
and brought to the laboratory immediately for examination. If this 
is impractical, some of the material may be deposited in a suitable 



MECONIUM. 265 

receptacle, and the small, grayish-white masses placed upon a 
warmed slide, if a warm stage is not at hand. One preparation 
after another must now he carefully looked over for actively mov- 
ing amoebae, or for amoeba-like bodies which exhibit definite move- 
ments (tor a description of these parasites see page 233). 

In addition to the amoeba?, other animal parasites may also be met 
with, such as the Trichomonas intestinalis, which is at times present 
in very large numbers. 

Red blood-corpuscles in greater or less abundance, numerous pus- 
corpuscles, more or less degenerated cylindrical epithelial cells, 
Charcot-Leyden crystals, bacteria of all kinds, and even large pieces 
of necrotic tissue may be found. 

Cholera Asiatica. — In this disease the stools are very numerous, 
being at first feculent, but soon becoming rice-water-like. As large 
a quantity as 200 grammes may be passed at each evacuation. The 
stools are colorless, almost odorless, watery, and on standing a finely 
granular, grayish- white sediment may be seen to form at the bottom. 
The reaction is neutral or alkaline. They contain only 0.5 per cent, 
of solids, a little serum-albumin, and a large amount of sodium 
chloride. In severe cases blood is present in variable amount. 
Microscopically, epithelial cells, triple phosphate crystals, and numer- 
ous micro-organisms are found. Of the latter, the comma-bacillus 
is, of course, the most important (see page 252). 

Typhoid Fever. — Typhoid stools are usually described as re- 
sembling pea-soup both in consistence and color. Their odor is 
generally highly offensive and characteristic. They contain a large 
amount of biliary coloring-matter and have almost always an alka- 
line reaction. Microscopically, many bile-stained epithelial cells, 
some leucocytes, many triple phosphate crystals, and an enormous 
number of micro-organisms, especially the Clostridium butyricum 
of Xothnagel and Eberth^s bacillus, are found. Later on, they may 
assume the appearance of ulcerative stools and become almost black, 
owing to the presence of blood. 

MECONIUM. 

By meconium are meant those masses which are first excreted from 
the bowel after birth. It is a thick, tenacious, greenish-brown mate- 
rial, which has accumulated during the intra-uterine life of the 
infant. Microscopically, a few cylindrical epithelial cells, a lew 
fat-droplets, numerous cholesterin-crystals, bilirubin-crystals, and 
lanugo-hairs are found. 

Micro-organisms are absent, but soon after suckling has com- 
menced they appear in abundance. The most important of those 
which are then constantly present are the Bacillus lactis aerogenes, 
which predominates in the small intestine, and the Bacillus coli 



266 THE FECES. 

communis, which is found more particularly in the large intestine. 
Both have already been described (see page Uoo , 

In addition to these, the Proteus vulgaris, Streptococcus coli brevis. 
Micrococcus ovalis, tetragenooocuSj Tornla cerevisise. TornJa rubra, 

aud a few less important micro-organisms have been found. 

Chemically, meconium contains bilirubin in considerable amount 
(recognizable by Gmelin's reaction . biliary acid-, fatty acids, chlo- 
rides, sulphates, phosphates of the alkalies aud their earths. It 
does not contain urobilin, glycogen, peptones, lactic acid, tyrosin. 
or leucin. 

An idea mav be formed of its composition from the following 
analysis of Zweifel •} 

Water 79.S-S0.5 per cent. 

-olid? 19.5-20.2 

Mineral matter 0.978 

Cholesterin 0.797 

Fats 0.772 

1 C. E. Simon. Physiological Chemistry, Lea Bros. a. Co.. Phila.. 1901. 






CHAPTER V. 

THE NASAL SECRETION. 

In the nasal secretion, which normally is small in amount, trans- 
parent, colorless, odorless, tenacious, and of a slightly saline taste, 
pavement-epithelial cells in large numbers, ciliated epithelial cells, as 
well as some leucocytes and an enormous number of micro-organisms, 
are found (Fig. Qti). Its reaction is alkaline. 

Fig. 66. 




Epithelial cells and mucous corpuscles found in the nasal secretion. 

In acute coryza the amount is diminished at first, but soon a very 
copious secretion occurs, which contains numerous epithelial cells 
and micro-organisms. When complicated with an ulcerative condi- 
tion pus is observed in considerable amount. 

Occasionally, as in cases of traumatism, cerebral tumors, etc., 
cerebrospinal fluid is discharged through the nose, and may be 
recognized by the fact that it is free from albumin and contains a 
substance which reduces Fehling's solution. 

Of pathogenic organisms, the tubercle bacillus and the bacillus of 
glanders may occur in ulcerative diseases of the nose, their presence 
indicating the existence of the corresponding affection. In ozsena a 
large diplococcus has been described by Lowenberg, which is said to 
be characteristic of the disease. Oidinm albicans has been observed 
in rare cases. The Meningococcus intracellularis of Weichselbaum, 
which is now quite generally regarded as the cause of epidemic 
cerebrospinal meningitis, has also been demonstrated in the nasal 
secretion of healthy individuals. This fact helps to explain the 
origin of those cases of meningitis which develop after injuries to 
the skull. 

267 



268 THE NASAL SECRETION. 

Ascarides and other entozoa have also been found. Charcot- 
Leyden crystals (see page 291) have been observed in the nasal 
secretion in cases of bronchial asthma and in connection with 
nasal polypi. Their presence is usually accompanied by the simul- 
taneous occurrence of eosinophilic leucocytes. 

Literature. — Eeimann, Baumgarten's Jahresber., 1888, vol. iii. p. 417. Lowenberg, 
Deutsch. med. Woch., 1885, vol. xi. p. 6, and 1886, vol. xii. p. 446. Tost, Ibid., p. 161. 
Gerber u. Podack, Deutscb. Arcb. f. klin. Med., 1895, vol. liv. p. 262. Leyden, Deutsch. 
med. Woch., 1891, vol. xvii. p. 1085. Sticker, Zeit. f. klin. Med., 1888, vol. xiv. p. 81. 
Nothnagel, Wien. med. Blatter, 1888, Nos. 6, 7, 8. 



CHAPTER VI. 
THE SPUTUM. 

GENERAL TECHNIQUE. 

The sputum should be collected in receptacles so constructed as 
to permit of their complete and easy disinfection. The paper spit- 
cups (Fig. 67) which have been introduced within late years are 
admirably adapted to this purpose, as they may be destroyed imme- 
diately after use. 

Fig. 67. 





Sanitary spit-cups. 

When working with sputa which are known or suspected to be of 
tubercular origin, the greatest care should be exercised to keep the expec- 
toration from drying and becoming disseminated in the air. Negligence 
in this respect may result in the most serious consequences. 

The macroscopical examination of sputa is most conveniently 
carried out by placing small portions of the material upon a plate of 
ordinary window-glass, of suitable size, which has been painted black 
upon its lower surface, and covering the same with a second, smaller 
plate. If it is desired to examine individual constituents which 
have been discovered in this manner, the upper plate is slid off until 
the particle in question is uncovered, when it may be removed to a 
microscopical slide and examined under a higher power. 

It is also very convenient to have a portion of the laboratory 
table painted black, when unstained plates of glass may be utilized. 
If these measure about 15 by 15 cm. and 10 by 10 cm., respectively, 
fairly large quantities of sputum may be examined in situ with a 
low power. 

269 



270 THE SPUTUM. 

GENERAL CHARACTERISTICS OF SPUTA. 

Amount. — The amount of sputum expectorated in the twentv- 
four hours varies within wide limits, depending largely upon the 
nature of the disease. Thus, only a few cubic centimeters may 
be eliminated, or the amount may reach 600 to 1000 c.c, and even 
more. Very large quantities are expectorated in cases of pulmonary 
hemorrhage and oedema of the lungs, also following the perforation 
of accumulations of pus from the thoracic or abdominal cavities into 
the respiratory passages ; furthermore, in cases in which large vomica? 
of tubercular or gangrenous origin exist, and finally in cases cf 
abscess of the lung, bronchiectasis, and even in simple bronchial 
blennorrhcea. In incipient phthisis, acute bronchitis, and in the first 
and second stages of pneumonia, on the other hand, the amount is 
usually small. 

In private practice, as well as in hospital work, an idea should 
always be formed of the amount expectorated in the twenty-four 
hours, especially in cases in which this is abundant. It is apparent 
that a copious and long-continued expectoration cannot continue 
without exerting very detrimental effects upon the patient's general 
nutrition ; in cases of pulmonary phthisis, for example, Renk has 
shown that 3.8 per cent, of all nitrogen eliminated in such cases is 
removed in this manner. Lenz in his recent experiments found even 
5 per cent. 

Consistence. — The consistence of the sputum corresponds, in a 
general way at least, to its amount, and may vary from a liquid to 
a highly tenacious state. The cause of the tenacity of the sputum 
is but imperfectly understood. The mucin present does not appear 
to be the most important factor, as it has been observed to occur 
in diminished amount in pneumonic sputa, which are noted for their 
high degree of tenacity. Ivossel 1 has suggested that the phenomenon 
may be due to the presence of nucleins or nuclein derivatives, while 
others again refer it to the presence of abnormal albuminous 
bodies of unknown character. However this may be, sputa are not 
infrequently seen where it is possible to invert the cup without 
losing a drop of its contents. This is observed especially in cases 
of acute croupous pneumonia up to the time of the crisis, pro- 
viding that a catarrh of the bronchi does not exist at the same 
time. It is noted, furthermore, immediately after an attack of acute 
bronchial asthma, and also in the initial stage of acute bronchitis. 
In cases of oedema of the lungs, on the other hand, the sputa are 
liquid and present the general characteristics of blood-serum, being 
covered, like all albuminous liquids when brought into contact with 
the air, by a frothy surface-layer. The sputa observed in cases of 
acute pulmonary gangrene, pulmonary abscess, putrid bronchitis, and 

1 Kossel, Zeit. f. klin. Med., 1883, vol. xiii. p. 152. 



GENERAL CHARACTERISTICS OF SPUTA. 271 

following perforation into the Lungs of an empyema <>r an accumula- 
tion of pus situated beneath the diaphragm, are fluid and consist of 
pure pus. 

Color. — The color of the sputa may vary greatly. They may he 
perfectly clear and transparent, gray, yellow, green, red, brown, and 
even black. Purely mucoid expectoration is almost transparent and 
colorless, as is also bhe sputum of pulmonary oedema when not mixed 
with blood or pus. 

The larger the number of leucocytes the more opaque does the 
sputum become, assuming at first a white, then a yellow, and finally 
a greenish color, the two latter colors being usually indicative of the 
presence of pus. Green sputa, however, may also be observed when 
bile-pigment has become admixed with the sputa, as in cases of perfo- 
ration of a liver-abscess into the lung. Green sputa may also be 
observed in cases of jaundice, and especially in pneumonia when 
accompanied by icterus. In cases of amoebic liver-abscess with 
perforation into the lung the sputa present a color resembling 
anchovy sauce, which is very characteristic. In one case I recog- 
nized the nature of the disease by simple inspection of the sputa. 1 

The inhalation of particles of carbon gives the sputum a grayish 
or even a black color ; the same or an ochre-yellow or red color is 
observed in cases of siderosis. 

A red color is usually indicative of the presence of blood, the in- 
tensity of the shade depending upon the character of the disease. 
It is seen especially after the formation of cavities, in caseous pneu- 
monia, in incipient phthisis, heart-disease, etc. In general, it may 
be said that a clear, bright-red color indicates an arterial, a dark- 
red or bluish-red a venous origin of the hemorrhage. The exact 
shade will depend upon the length of time that the blood, no matter 
what its origin may be, has remained in the lungs. In pulmonary 
gangrene a dirty brownish-red color is observed, owing to the pres- 
ence of methsemoglobin, and, to some extent also, of hsematin. 
Quite characteristic is a chocolate color, which is observed when a 
croupous pneumonia terminates in necrosis and gangrene. Equally 
characteristic is the rusty and prune-colored expectoration seen in 
cases of pneumonia. Occasionally a breadcrust-brown color is 
observed in cases of gangrene and abscess of the lung, which is 
quite characteristic, the color being due to the presence of haematoidin 
or bilirubin. 

Rust-colored punctate or striped sputa, moreover, are said to be 
diagnostic of* brown induration of the lung. 

Odor. — Most sputa are odorless. Under certain conditions, how- 
ever, there may be a very marked odor. In cases of pulmonary 
gangrene or putrid bronchitis the odor is of a kind never to be for- 
gotten, the stench, indeed, being frightful. A somewhat similar, 

1 See Johns Hopkins Hosp. Bull., November, 1890. 



272 THE SPUTUM. 

slightly sweetish odor is observed in certain cases in which putre- 
factive organisms have entered the lungs, and there exert their action 
upon the accumulated sputa, in the absence of gangrene, as in cases 
of bronchiectasis, perforating empyema, and where ulcerative proc- 
esses are taking place in the lungs, whether these be of tubercular 
origin or ^ not, An odor like that of old cheese is occasionally 
observed in cases of perforating empyema ; under such conditions 
tyrosin is usually found. This body, however, has nothing to do 
with the odor of the sputa ; both factors are merely indicative of 
certain putrefactive changes going on in the lungs. According to 
Leyden, the occurrence of tyrosin in sputa is usually indicative of 
the perforation of an old accumulation of pus into the lungs. 

Specific Gravity. — The specific gravity of sputa varies within 
wide limits ; mucous sputa have a specific gravity of 1.004 to 1.008, 
purulent sputa one of 1.015 to 1.026, and serous sputa one of 1.037 
or more. 

Configuration of Sputa.— As a general rule, the following forms 
of sputa, which may be termed pure sputa, present a homogeneous 
appearance : 

Mucoid sputa, ] 

Purulent sputa, I TT 

Serous sputa, f Homogeneous sputa, 

Sanguineous sputa, J 

with one exception, perhaps — the typically rusty sputa of croupous 
pneumonia ; while mixtures of any two or three of these may be 
classed as heterogeneous sputa : 

Mucopurulent sputa, 
Mucoserous sputa, -,-,- . 

Serosanguineous sputa, f Heterogeneous sputa. 

Sanguino-mucopurulent sputa, J 

The so-called sputum crudum of the first stage of acute bronchitis 
may be regarded as an example of a purely mucoid sputum. A 
purely purulent sputum is usually indicative of the perforation of an 
empyema or any other accumulation of pus into the lungs or bronchi, 
of pulmonary abscess, or of bronchial blennorrhea. A purely serous 
sputum is found in cases of pulmonary oedema, and a purely hemor- 
rhagic sputum in cases of severe pulmonary hemorrhage. 

Of the heterogeneous sputa, the most important are the so-called 
nummular sputa of the second and third stages of phthisis. These 
are characterized by the fact that when thrown or expectorated into 
water they sink to the bottom, and there form coin-like disks, from 
which property they have received their name. Such sputa are 
mucopurulent in character, and contain a focus of almost pure pus 
imbedded in a more or less homogeneous mass of mucus. Quite 
different from these are the so-called sputa globosa of the ancients, 
which consist of fairly dense, roundish, grayish-white masses ; they 



MICROSCOPICAL CONSTITUENTS OF SPUTUM. 273 

arc secreted in old cavities which have become lined with a granu- 
lation-membrane. 

Very important is the presence of small, cheesy particles, which are 
occasionally found at the bottom of the spit-cup. They vary in size 
from that of a millet-seed to that of a pea, and are observed espe- 
cially in the second and third stages of phthisis. Usually they con- 
tain tuberele bacilli in large numbers, and frequently also elastic 
tissue. Not to be confounded with these, are certain small, caseous 
masses which are at times expectorated by perfectly normal indi- 
viduals, and also by patients suffering from acute tonsillitis, ozrena, 
etc.. and which probably come from the tonsils or mucous cysts. 
Formerly they were regarded as tubercles, and in hypochondriac 
individual- their expectoration may cause a great deal of anxiety. 
They are quite readily distinguished from the true caseous masses 
expectorated by phthisical individuals by the following character- 
istics : as a rule, they are expectorated unaccompanied by pus or 
even by mucus ; rubbed between the fingers they emit an extremely 
offensive odor, which is referable to the presence of fatty acids ; an 
examination for tubercle bacilli, moreover, will prove entirely nega- 
tive. Quite characteristic, furthermore, is the peculiar, finely floc- 
culent, granular appearance of the sputa seen after perforation of 
an empyema into the lungs through a small aperture, which is not 
followed by pneumothorax. 

Occasionally, as in putrid bronchitis, and gangrene of the lungs, 
and also in chronic bronchitis, ultimately leading to the formation 
of bronchiectatic cavities, an exquisite sedimentation is observed. 
Such sputa when collected in a conical glass present three distinct 
zones : the one at the bottom contains the cellular elements of the 
sputum, the second the pus-serum ; and the third or superficial 
layer consists of mucus and contains many air-bubbles. 

MICROSCOPICAL CONSTITUENTS OF SPUTUM. 

Elastic Tissue. — Of macroscopical constituents which may be 
observed in sputa, there may be mentioned, first of all, the occur- 
rence of threads of elastic tissue and pulmonary parenchyma, which 
are seen in cases of phthisis, pulmonary abscess, and gangrene. As 
their ultimate recognition, however, largely depends upon a micro- 
scopical examination, this subject will be considered later on. 

Fibrinous Casts. — Fibrinous casts are observed especially in 
cases of croupous pneumonia (Fig. OS), immediately before or after 
resolution has taken place. They are seen also in cases of so-called 
fibrinous bronchitis (Fig. 69), and in diphtheria, when the membrane 
ha- extended into the finest ramifications of the bronchi. These 
easts may vary in size from 12 cm. in length by several millimeters 
in thickness to small fragments which measure only from 0.5 to 3 

18 



274 



THE SPUTUM. 
Fig. 68. 




Fibrinous coagulum from a case of croupous pneumonia. (Bizzozero.) 
Fig. 69. 




Fibrinous coagulum from a case of plastic bronchitis, (v. Jaksch.) 

cm. in length. The fibrinous casts observed in cases of pneumonia. 



MICROSCOPICAL CONSTITUENTS OF SPUTUM. 270 

usually from the third to the seventh day, are of the latter size or 
even smaller, being derived from the ultimate twigs of the finest 
bronchioles. Those found in the rather rare disease, fibrinous bron- 
chitis, stand betWeen these two in size, being casts of the smaller and 
medium-sized bronchi. Attention is usually attracted to the presence 
of such easts by their white color; often, however, they are yellow- 
ish brown or reddish yellow, owing to the presence of blood-coloring 
matter which has become deposited upon the casts; at other times 
they are enveloped in mucus, when their recognition may become 
quite difficult. Such casts, when examined carefully, will be seen to 
branch dichotomously, and to contain a cavity in their larger portion, 
while the finer branches appear to be solid. Microscopically, they 
may be shown to consist of a large number of fibres, which are 
arranged longitudinally or in a net-like manner, and contain blood- 
corpuscles and epithelial cells in their meshes. When treated with 
Weigert's fibrin-stain they are beautifully resolved. Charcot-Leyden 
crystals have at times been observed in these formations. 

Whenever it is desired to examine sputa for casts it is best to 
pick out particles that look promising, upon a dark or light surface, 
and then to shake them out in water. For such purposes Kronig's 
sputum-plate can be recommended. 

Curschmann's Spirals. 1 — Quite distinct from the formations 
just described are the so-called spirals of Curschmann, which are 
observed especially in cases of true bronchial asthma, but occur also 
in chronic bronchitis, and even in croupous pneumonia. Upon 
careful examination they w T ill be seen to consist of thick, yellowish- 
white masses, which exhibit a spirally twisted appearance, and are 
characterized, moreover, by their more solid consistence and light 
color. On microscopical examination they are seen to be composed 
of a spirally twisted network of extremely delicate fibrils, containing 
epithelial cells and numerous leucocytes ; the latter are almost all 
of the eosinophilic variety. 2 Usually, but not invariably, Charcot- 
Leyden crystals also are seen. 3 The spirally twisted mass is found 
to be wound around a central, very light and clear thread, which 
usually has a zigzag course (Fig. 70). 

Other formations, probably mere varieties of those just described, 
have also been observed, in which the central thread is absent or in 
which the spiral arrangement is deficient. The spiral form, how- 
ever, with the central thread, must be considered as the most char- 
acteristic. Their length and breadth may vary a great deal, but 
rarely exceed 1 to 1.5 cm. Their occurrence seems always to indi- 
cate a desquamative catarrh of the bronchi and alveoli, but practi- 

1 Leyden, Virchow's Archiv, 1872, vol. liv. p. 328. Curschmann, Deutsch. Arch. f. 
klin. Med., 1883, vol. xxxii. p. 1. and vol. xxxvi. p. 578. v. Jaksch, Centralbl. f. klin. 
Med.. 1883, vol iv. p. 497. 

2 Schmidt, Zeit. f. klin. Med., 1S92, vol. xx. p. 92. v. Xoorden, Ibid., p. 98. 

3 Leyden, loc. cit. 



276 THE SPUTUM. 

eally nothing is known concerning their formation. If in a given 
case the diagnosis rests between trne bronchial and what may be 
termed reflex asthma, the presence of these formations points to the 
existence of the former disease. Chemically, the spirally wound 

Fig. 70. 










A Curschmann spiral from a case of true bronchial asthma. 

mass seems to consist of a mucinous substance, while the central 
thread is possibly of fibrinous origin. 

Charcot-Leyden crystals (Fig. 71), which are usually absent at 
the beginning of an attack of asthma, at which time only the spirals 
are observed, may be seen to develop from the spirals when these 

Ftg. 71. Fig. 72. 








^° / 



Wall of a hydatid cast, showing 
the laminated structure ; not mag- 
Charcot-Leyden crystals. (Scheube.) nified. (Dayai>'e. 



o 



are kept for several days. They will be considered later on in 
studying the chemistry of the sputum. 

Echinococcus Membranes. — Echinococcus membranes come 
from a perforating cyst of the liver, kidney, or lung. They consti- 
tute rather thick, and at the same time tough, pieces of membrane 
(Fig. 72) ; occasionally entire sacs are seen, of the color of white 
porcelain, in sections of which it is possible to make out a fibrillated 
structure. The disease is rare in this country. 



PLATE XIII. 



en 



M - 










Sputum from a ease of Bronchial Asthma, showing large num- 
bers of Eosinophilic Leucocytes and Free Granules. 



It will be noted that the leucocytes are all mononuclear. [Eye-piece i, objective 1-8, Bausch and L i 



MI( 'BOSi -oru '. I L I.X. l MIX. I TION. 277 

Concretions. — Still rarer is the expectoration of concretions which 
have formed in dilated portions of the bronchi or in tubercular 

cavities, or of calcified bronchial glands that have found their way 
into the Lungs. Curious examples of the occurrence of such con- 
cretions have been reported. Andral thus cites a case of phthisis 
in which within eight months as many as 200 stones were expec- 
torated, and Portal mentions a case in which 500 were thus expelled. 1 
Foreign Bodies. — Foreign bodies which have accidentally entered 
the air-passages and have remained there for a long time may also 
be found in the sputum. Heyfeldcr mentions a case in which a 
man coughed up a wooden cigar-holder with pus and blood after 
eleven and a half years. 

MICROSCOPICAL EXAMINATION. 

Under this heading it is necessary to consider leucocytes, red 
blood-corpuscles, epithelial cells, elastic fibres, corpora amylacea, 
parasites, and crystals. 

Leucocytes. — Leucocytes, usually poly nuclear in character, are 
found in every sputum in considerable numbers, imbedded in a 
homogeneous, more or less tenacious material. At times they appear 
very granular, containing fat-droplets, or granules of pigment, such 
as carbon or hematoidin. Their number varies considerably, being 
naturally greatest in cases of perforating abscess, empyema, putrid 
bronchitis, etc. 

While the leucocytes which usually are found in the sputum are 
of the neutrophilic variety, eosinophiles may also be observed, and 
especially in asthmatic sputa, in which they often predominate. 
Free eosinophilic granules are then also seen, and I have repeatedly 
observed specimens in which the spirals (see above) were literally 
covered with these granules (Plate XIII.). The presence of eosino- 
philic leucocytes is, however, not characteristic of the sputa of 
bronchial asthma, as they may be met with in other diseases as 
well. Teichmiiller has pointed out that they are present in a large 
percentage of tubercular cases, and may be found months before 
tubercle bacilli can be demonstrated. He regards their occurrence 
as evidence of a defensive struggle on the part of the body, which 
is most evident in fairly strong individuals. In recovery a gradual 
increase in their number is always noticeable, and a diminution, 
Teichmiiller thinks, is indicative of a relapse, or, if the diminution 
occurs rapidly, of florid consumption. These statements, however, 
lack confirmation and are probably too dogmatic. The same observer 
has also described an "eosinophilic" bronchitis, which differs 
from other forms of the disease in the abundance of eosinophilic 
cells which are encountered. The sputum in such cases i- described 

1 L. W. Atlee, " Bronchial Concretions," Am. Jour. Med. Sci., 1901, vol. exxii. p. 49. 



278 THE SPUTUM. 

as transparent, mucoid, and loose, with yellow purulent admixtures. 
It is said to be markedly different from the tough, thick sputa of 
bronchial asthma. Typical spirals are absent, but rudimentary 
forms may be encountered. Charcot-Leyden crystals are present. 1 

Basophilic leucocytes have also been observed in the sputa. 

Red Blood-corpuscles. — The presence of red blood-corpuscles in 
small numbers does not, by any means, indicate serious pulmonary or 
cardiac disease, as they may be found in almost any sputum, and 
especially in that of individuals who smoke much or live in a smoky 
atmosphere ; they are, without doubt, derived from the catarrhally 
inflamed bronchial or tracheal mucosa. Whenever they occur in 
large numbers, however, their presence becomes important. They 
may be observed in acute bronchitis, pneumonia, oedema of the 
lungs, bronchiectasis, abscess, gangrene — in fact, in all pulmonary 
diseases. Their occurrence is most important in phthisis, and is, in 
fact, one of the most constant symptoms of the disease. 

The form of the red corpuscles will depend upon the length of 
time they have remained in the lungs, and all gradations from the 
typical red corpuscle to its shadow, or even fragments, may thus be 
observed. In pneumonia the microscopical examination may at 
times be disappointing, the appearance of the sputum suggesting 
that red corpuscles in large numbers are present, while, as a matter 
of fact, they are almost all destroyed, the color being due to altered 
pigment. It may even be necessary at times to depend upon chemi- 
cal methods to clear up any doubt as to the source of the color of 
the sputum. It should always be remembered that the presence of 
blood-pigment is not always indicated by a red color, but that it may 
also assume a golden-yellow or even a greenish tinge, owing to cer- 
tain chemical changes which have taken place. The golden-yellow 
and the grass-green sputa observed in cases of pneumonia during 
convalescence belong to this class. 

To demonstrate the presence of traces of blood in the sputum, 
Donogany's method, or that of Muller and Weber, may be con- 
veniently employed. With the former method the sputum is first 
boiled with a 20 per cent, solution of sodium hydrate (see page 199). 

Epithelial Cells. — Epithelial cells may also be observed in the 
sputum. While a great deal of information might be expected from 
their presence from a diagnostic point of view, as accurately indi- 
cating the parts of the respiratory tract attacked by disease, the data 
obtained are practically of little value. 

Cylindrical epithelial cells, providing they do not come from the 
nose, indicate in a general way an inflammatory condition of the 

1 Teichmiiller, "Die eosinophile Bronchitis," Deutsch. Arch. f. klin. Med., vol. 
lxiii. Hefte 5, 6. See, also. K. Schonbrod, Ueber den gegenwiirtigen Stand der Beurtbei- 
lung der eosinophilen Zellen im Blute und im Sputum, Inaug. Diss.. Erlangen, 1895. 
A. Hein, Ueber das Vorkommen eosinophiler Zellen im Sputum, Inaug. Diss., Erlan- 
gen, 1894. 



MICR OS CO PIC A L EX A MINA TION. 



279 



lower larynx, trachea, or bronchi. They are not of much impor- 
tance, however, as their form is usually so much altered that it is 
often difficult to recognize them ; they may thus become polyhedral, 
cuboidal, or even round, and can then hardly be distinguished from 
Leucocytes. Actively moving cilia can be found only in perfectly 
fresh sputa, immediately after being expectorated. If ciliated epi- 
thelial cells can be definitely recognized in a sputum, it may be in- 
terred that we are dealing with a pathological condition of an acute 
nature, providing, of course, they did not come from the nose. 

Formerly much importance was attached to the so-called alveolar 
epithelial oells (Fig. 73) as an aid in diagnosis. Buhl thus imagined 
these, particularly when undergoing fatty or myelin degeneration, 
to be absolutely pathognomonic of pulmonary disease, and especially 
of that form of pneumonia which has been termed essential idio- 
pathic desquamative pneumonia. Bizzozero, however, as well as 

Fig. 73. 




Epithelium, leucocytes, and crystals of the sputum. (Eye-piece III., objective 8 A, Reich- 
ert.) a, a', a", alveolar epithelium; b, myelin forms; c, ciliated epithelium; d, crystals of 
calcium carbonate : e, haematoidin crystals and masses : /,/,/, white blood-corpuscles ; g, red 
blood-corpuscles; h, squamous epithelium, (v. Jaksch.J 

others, has shown that these cells not only occur in almost every 
known pulmonary disease, but that they are present also in the so- 
called "normal" expectoration which at times is obtained upon 
making a very forcible expiration. 

Bizzozero * describes these cells as round, oval, or polygonal bodies, 
varying in size from 20 }i to 50 fi. They may contain one, two, or 
three oval nuclei, which are rather small and provided with nucleoli. 
Usually the latter are hidden beneath numerous granules. Some of 
these granules are albuminous, but most of them are either pigment- 
granules, fatty granules, or myelin granules. The myelin granules 
were first discovered by Virchow 2 in 1854, and termed myelin gran- 
ules on account of their resemblance to mashed nerve-matter. They 
are distinguished from the other forms by their clear, pale, color- 

1 Bizzozero, Microscopic clinique, 2d ed. Francaise, Paris, 1885. 

2 Virchow, Virehow's Archiv, 1854, vol. vi. p. 562. 



280 



THE SPUTUM. 



less appearance, and the fact that at times fine concentric striations 
can be detected. These forms may be round, but more often they 
are irregular. At times fatty, myelin, and pigment -granules may 
be seen in one and the same cell. Possibly they are derived from 
the pulmonary alveoli, but this is still an open question. Chemi- 
cally, the myelin droplets have been shown to contain a considerable 
amount of protagon, besides traces of lecithin and cholesterin. 1 

Liver-cells may at times be observed in the sputa in cases of liver- 
abscess, and are easily recognized by their characteristic form. 

Elastic Tissue. — Much more important from a clinical stand- 
point are the elastic fibres and shreds of elastic tissue which may 
be found in sputa. They vary much in length and breadth, and 
are provided with a double, undulating contour ; they are usually 
curled at their ends. Very often they exhibit an alveolar arrange- 
ment (Fig. 74), which at once determines their origin. 

Fig. 74. 




Elastic fibres in the sputum. (Eye-piece III., objective 8 A, Reich ert.) (v. Jaksch.) 



Whenever present, elastic tissue is an absolute indication that a 
destructive process is going on in the lungs. It is found in cases 
of abscess of the lungs, bronchiectasis, occasionally in pneumonia, 
and, most important of all, in phthisis. In gangrene of the lung 
elastic tissue is usually not found ; this is probably owing to its 
destruction by a ferment, as suggested by Traube. 

In everv case it is necessary to determine whether the elastic 
tissue may not be owing to the presence of animal food in the 
sputum, and it may, hence, be stated as a rule that it can only 
be regarded as absolutely characteristic when showing the alveolar 
arrangement. 

In order to demonstrate the presence of elastic tissue in the 

1 A. Schmidt, "Ueber Herkunft u. chem. Natur d. Myelinformen d. Sputums," 
Berlin, klin. Woch., 1898, p. 73. See, also, Zoja, Maly's Jahresberichte, vol. xxiv. 
p. 694. 



MICROSCOPICAL EXAMINATION. 281 

sputum, it is necessary to examine large quantities with a moder- 
ately low power, and best alter the addition of a strong solution 

of sodium hydrate. The sputum may also be boiled with a 10 per 
cent, solution of the reagent, an equal volume being added ; alter 
dilution with four times its volume of water it is allowed to settle 
for twenty-four hours. The centrifugal machine will here be found 
of great assistance. 

The following method, in use at the Johns Hopkins Hospital, is 
most convenient: a small amount of the thick, purulent portion 
of the sputum is pressed out into a thin layer between two pieces of 
plain window-glass, 15 by 15 cm. and 10 by 10 cm. The particles 
of elastic tissue appear on a black background as grayish-yellow 
spots, and can be examined in situ under a low power. Or, the 
upper piece of glass is slid off till the piece of tissue is uncovered, 
when it is picked out and examined on a slide, first with a low and 
then with a higher power. At first there will be some difficulty in 
distinguishing with the naked eye between elastic fibres and particles 
of bread, or milk globules, or collections of epithelium and debris, 
but with practice such mistakes are rarely made, and the microscope 
always reveals the difference. 

To stain elastic tissue, Michaelis suggests the following method : 
suspected bits of sputum are spread upon a slide in a thin layer, dried, 
and then placed for one-half hour in a jar containing Weigert's solu- 
tion. The specimen is then washed with water, decolorized in acid 
alcohol (containing 3 per cent, of hydrochloric acid), dried, covered 
with a thin layer of oil of cedar, and examined without a cover-glass 
with a low power ; the elastic fibres are stained a dark violet. 

Weigert's Elastic Tissue Stain. — This is prepared as follows : 
200 c.c. of an aqueous solution of fuchsin and resorcin, containing 
1 and 2 per cent, of the ingredients, respectively, are boiled in a 
porcelain dish. When the boiling-point is reached 25 c.c. of liquor 
ferri sesquichloridi (Ph. G. III.) are added. While stirring the 
solution is boiled for from two to five minutes longer. It is then 
allowed to cool ; the precipitate is collected on a filter, dried, and 
boiled in 200 c.c. of 94 per cent, alcohol while stirring. On cool- 
ing, alcohol is added to the 200 c.c. mark, when the solution is 
treated with 4 c.c. of hydrochloric acid, and is ready for use. 

Animal Parasites. 

Portions of echinococcus cysts, viz., pieces of membrane (Fig. 73) 
and booklets (Fig. 75), are occasionally seen when the parasite has 
lodged in the lungs or in the neighboring organs. The disease, 
however, is exceedingly rare in this country. 

The adult parasite (Fig. 76), Taenia eefdnocoecus (v. Sicbold), is 
found in the intestinal canal of the dog, the dingo, the jackal, the 



1-1 THE SPUTUM. 

wolf, etc, The larval form, Eehmoeoeeug polymorphus, develops in 

cattle, sheep, and swine, and is also found in man. The parasite, in 
fact, is the most dangerous animal parasite which is encountered 
in the human being. In America it is at present not common. 




H: :>Lt:s ir:~ -su:.. e :liu:-: :■■::- us. • >:•" 

If the eggs of the parasite are introduced into the digestive tract 
of man, the einbrvos may make their way into the lungs, liver, or 
other organs, and there give rise to the formation : — . inch 
are often of enormous size. The body of the adult animal is from 

Fig. 

_A_ C V 




'7-£ --^-.^' 




4 to 5 mm. long, with only 3 or 4 segments, the largest of which 
mav measure 0.6 mm. in length by 2 mm. in breadth. On the 
head there are Iron. 28 50 booklets (see F _ 

omonac at times been observed in cases of gangi 

: Hvdatid disease in man: Neraar, Die EchincKroccen-Krankheit^ 1S77. Berlin. 
Da T3 J g tozoaires et des Maladies vennineuses. Paris, 15 ... 2d ed. 



MICROSCOPh '. I L i:x. 1 .1//.V. I TION. 283 

of the lung, and in the pus removed post mortem from lung-cavities. 
They are identical with the Trichomonas vaginalis of Donne. 

Most important is the presence of the Anuria coli, as the diag- 
nosis of hepatic abscess with perforation into the lung may he made 
in every instance in which this organism is encountered in the 
sputa (see Feces). 1 

A form of pulmonary disease closely simulating phthisis is very 
common in Japan, and has been shown to be referable to the pres- 
ence of a parasite in the lungs, the Distoma pulmonale, Balz : syn., 
Distoma Westermanni (Kerbert), Distoma Ringeri (Cobbold). The 
worm and its ova are found in the sputum. " The parasite is 8 to 
10 mm. long, 5 to 6 mm. wide, of a club shape, rounded very 
markedly in front, less rounded posteriorly. The color during life 
is almost like that of earth-worms. The two sucking disks are 
nearly equal in size. The ova are brown, with a thin shell, lidded, 
0.1 mm. long and 0.05 mm. wide." (Huber.) 

In this country the parasite has been found in the cat and in the 
dog ; in the human being one case at least, occurring in a Japanese 
student, has been reported. 2 It is interesting to note that many 
Charcot-Leyden crystals are at the same time found in the sputum. 3 

Manson found the ova of a species of Distoma haematobium in the 
bloody expectoration of a Chinaman who had lived for some time on 
the island of Formosa. 

Vegetable Parasites. 

Pathogenic Organisms. — The Tubercle Bacillus. — The most im- 
portant vegetable parasite met with in the sputa is the bacillus of 
tuberculosis. The history of the discovery of this organism, and the 
theories which were held before its pathogenic importance was estab- 
lished, cannot be considered here. Suffice it to say that the study 
of bacteriology has given no other discovery of equal importance 
from a clinical point of view. How primitive and wholly inadequate 
were the means formerly employed in making the diagnosis of this, 
the most formidable disease of modern times ! The presence or 
absence of elastic tissue in the sputa was practically all that 
physicians had to guide them beyond the history of the patient 
and the results of a physical examination. The demonstration of 
elastic tissue, however, a- has been pointed out, merely indicates the 
existence of a destructive process in the lungs. Under such condi- 
tions it was of necessity impossible to diagnose tubercular disease 
in its incipiency. It is true that cases are occasionally observed in 
which tubercle bacilli are never present in the sputa, and are only 
discovered post mortem. Such cases, however, are extremely rare, 

1 C. E. Simon, Johns Hopkins Hosp. Bull., Nov.. 1S90. 

2 C. W. Stiles, "Distoma Westermanni,' 9 Johns Hopkins Hosp. Bull., 1894, p. 57. 

3 Braun, Die thierischen Parasiten, etc.. Stuber, Wurzbarg, L895. 



284 THE SPUTUM. 

and do not in the least detract from the importance which attaches 
to careful and repeated examinations of the sputa in all doubtful 
cases. 

From a macroscopical examination it is impossible to decide 
whether or not a particular sputum is of tubercular origin. At times 
a sputum may have a suspicious appearance, but it is never possible 
to speak with certainty from simple inspection, as a mucoid sputum 
may contain tubercle bacilli in large numbers, while a mucopurulent 
sputum may be entirely free from them, and vice versa. Reliance 
should, hence, only be placed upon a careful microscopical examina- 
tion. When found, their presence is, of course, pathognomonic. A 
negative result, however, does not exclude the existence of tuber- 
cular disease. The possibility that they may be altogether absent 
from the sputum has been mentioned. In some instances they may 
be present at times and absent at others. In all cases in which the 
existence of phthisis is suspected, it is imperative to make use of 
every device which may aid in its detection. In this connection, 
I wish to insist upon the method of "growing the bacilli," as it 
were, in the warm chamber for from twenty-four to forty-eight 
hours, and then re-examining the sputa in doubtful cases, as 
Xuttall x demonstrated beyond a doubt that the tubercle bacillus 
will multiply in the sputum itself at a certain temperature. The 
value of this observation is obvious, and I have repeatedly been 
able to demonstrate their presence in this manner Avhen it was 
impossible to detect them in the fresh sputum. The centrifugal 
machine in such cases is also useful and yields valuable results, the 
probabilities of finding the bacilli when present in small number 
being very much increased. 

If but few bacilli are present, the following procedure may also 
be employed : about 100 c.c. of sputum are boiled with double the 
amount of water, to which from six to eight drops of a 10 per cent, 
solution of sodium hydrate have been added, until a homogeneous 
solution has been obtained, water being added from time to time to 
allow for evaporation. The mixture is then centrifugated or set 
aside for twenty-four to forty-eight hours and examined for tubercle 
bacilli and elastic tissue. 

In the examination of tubercular sputa the fine caseous particles 
previously described (page 273) should be carefully sought for, as 
they contain the largest number of bacilli. In their absence reliance 
should be placed upon the examination of a large number of prepa- 
rations. 

If, notwithstanding the fact that all due precautions have been 
taken, no bacilli can be demonstrated in the sputum, and the clinical 
history and the physical signs are indefinite or negative, the proba- 
bilities are that we are dealing with a benign process. From an 

1 Xuttall, Johns Hopkins Hosp. Bull., 1891. 



Mli 'i:os( OPIQA L EXAMINATION. 285 

examination of the sputa alone in such cases it is utterly impossible 
to reach a definite conclusion. When the amount of sputum, more- 
over, is small and contains but little pus, the absence of tubercle 
bacilli in doubtful eases is less suggestive of the absence of tuber- 
cular disease than in eases in which the sputum is more abundant 
and mucopurulent. 

Only two bacilli are likely to be mistaken for the tubercle ba- 
cillus, viz., the bacillus of leprosy and the smegma bacillus. All 
three are characterized by the difficulty with which they take up 
basic dyes, and the great tenacity with which these are retained 
when once stained, even upon treatment with mineral acids. This 
peculiarity has been quite generally referred to the presence of fat 
in the bacilli, but it appears from more recent researches that the 
chitin or chitinous substances in the bodies of the tubercle bacilli 
are at least primarily concerned in the reaction (Helbing 1 ). Sata, 2 
moreover, has shown that other bacteria, such as the anthrax bacillus, 
the bacillus of glanders, the Staphylococcus aureus, etc., give a fat 
reaction which is as intense as that of the tubercle bacillus, while 
these organisms are not in the least resistant to the action of acids 
when stained. 

That confusion should arise iu the differentiation between the 
tubercle bacillus and the bacillus of leprosy is very unlikely. More 
important is the smegma bacillus, which is now known to occur at 
times upon the tonsils, the tongue, and in the tartar of the teeth of 
perfectly healthy individuals. In sputum coming from the lungs 
it has been observed by Pappenheim, 3 Frankel, 4 and others. To 
Pappenheim we are indebted for a method by which we are enabled 
to differentiate such cases from tuberculosis. This is essentially 
based upon the greater ease and rapidity with which the smegma 
bacillus is decolorized by means of nuorescem-alcohol, as compared 
with the tubercle bacillus. As the other methods which have hitherto 
been in use in the clinical laboratory do not permit of differentiation 
between the two organisms, I have given Pappenheim's method the 
first place, but have retained the others also. They may be em- 
ployed as heretofore, unless special reasons exist for eliminating the 
smegma bacillus, the occurrence of which in the sputum must after 
all be regarded as a medical curiosity. In the examination of 
urinary deposits, however, in which the smegma bacillus is far more 
commonly seen, these older methods are not applicable (see Urine). 

Methods of Staining the Tubercle Bacillus. — 1. Pappm- 

1 C. Helbing, " Erklamng-sversuch f. d. specifische Farbbarkeitd. Tuberkelbacillen," 
Deutsch. med. Woch., 1900. V. B. p. 133. 

2 Sata, " Ueber d. Fettbildung durch verscbiedene Bakterien," etc., Centralbl. f. 
all-. Path. u. path. Anat., 1900, Noa. 3, 4. 

3 A. Pappenheim, "Beftmd v. Smegmabacillen im menscblicben Lungenauswurf," 
Berlin, klin. Woch.. 1898, No. 37. 

4 A. Frankel, " Binige Bemerkungen viber d. Vorkommen v. Smegmabacillen im 
Sputum," Ibid., 1898, p. 880. 



286 THE SPUTUM. 

helm's Method. 1 — A drop of the sputum — or, if the cheesy particles 
described above, are present, one of these — is spread in a thin layer 
between two cover-glasses. These are then drawn apart, dried in 
the air, and fixed by being passed three times through the flame of 
a Bunsen burner or an alcohol lamp. Larger quantities of the 
sputum may also be employed, and are spread upon slides and 
examined in the same manner, a drop of immersion oil being 
placed directly upon the dried and stained preparation. The speci- 
mens are covered with a few drops of carbol-fuchsin solution and 
heated to the boiling-point. The solution is composed of 1 part of 
fuchsin, 100 parts of a 5 per cent, solution of carbolic acid and 10 
parts of absolute alcohol. The excess of the staining fluid is drained 
off, when the preparations are immersed from three to five times in 
Pappenheim's solution, care being taken to let the fluid drain off 
slowly after each immersion. The reagent consists of 1 part of 
corallin (rosolic acid) in 100 parts of absolute alcohol, to which 
methylene-blue is added to saturation. This mixture is further 
treated with 20 parts of glycerin, and is then ready for use. The 
specimens are finally washed in water, dried between filter-paper, 
and mounted in balsam or oil of cedar. A -^ oil immersion lens is 
very convenient, but not a necessity, as the organisms are seen quite 
readily with lower powers, such as Zeiss' DD, Leitz' 7, or Bausch 
and LomVs jr or -|, with a correspondingly high eye-piece. 

2. Gabetfs Method. — The dried preparations are floated for two 
minutes upon the carbol-fuchsin solution described above, and are 
immediately transferred, without washing, to a solution composed 
of 2 parts of methylene-blue in 100 parts of a 25 per cent, solu- 
tion of sulphuric acid, in which they remain one minute. They are 
then washed in water and mounted. 

This method of staining is very convenient, and is the one most 
generally employed. The smegma bacillus, however, is also stained. 2 

3. The Weigert-JEhrlich Method. — Dried specimens are prepared, 
and stained for twenty-four hours with a solution of fuchsin in 
anilin-water, by floating upon the surface. The staining fluid is 
prepared as follows : 

A small test-tube full of water is shaken with about twenty drops 
of pure anilin oil (1 : 20), and after standing for a few minutes fil- 
tered through a moistened filter. To this solution a few drops of a 
concentrated alcoholic solution of fuchsin or of methyl-violet are 
added until the mixture becomes slightly cloudy — i. e., until a metal- 
lic lustre is noted on the surface. After twenty-four hours the 
preparations are washed with water in order to remove an excess of 
staining fluid. They are then immersed for several seconds in a 

1 Pappenheim, loc. cit. 

2 Frankel, Berlin, klin. Woch., 1884, vol. xxi. p. 195 ; and Deutsch. med. Woch., 1887, 
vol. xvii. p. 552. 



PLATE XIV. 



'/T 



;, a 






h^i 



// 



Tuberculous Sputum Stained by Gabbett's Method. The Turberele Bacilli 
are seen as Red Rods, all else is Stained Blue. (Abbott.) 



FIG. 2. 




L. SCHMIDT, FEC. 



The Diploeoeeus Pneumoniae, Stained with Methylene Blue and Fuchsin 
as a Counterstain. Taken from the Sputum of a Case of 
Acute Croupous Pneumonia. 

FIG. 3. 









£ 



£ « 






4* 






Heart-Disease Cells, showing Alveolar Epithelial Cells, Loaded Down 
with Granules of Haematin. 



MI( 'ROSCOPIC. 1 L i:x. 1 MIX. I TION. 287 

dilute solution of nitric or hydrochloric acid (1 : 6, 1 : 3, or 1 : 2 ), and 

washed again with water or with absolute alcohol. At this time the 
specimens should have a faintly red or violet color. They are then 
dried between layers of filter-paper or in the air, and mounted as usual. 

If it is desired to use a counter-stain, Bismarck-brown, vesuvin, 
or methvlene-blue in watery solutions may be used for the purpose. 
Into such a solution the specimen is placed after treatment with 
nitric acid and washing in water. It remains for about two min- 
utes, and is then washed, dried, and mounted as above. 

4. Ziehl-Nedsen's Method. — A mixture of 90 parts of a 5 per cent. 
solution of carbolic acid and 10 parts of a concentrated alcoholic 
solution of fuehsin is used. The procedure is the same as that 
described under the Weigert-Ehrlich method. With both methods, 
however, it is unnecessary to stain the preparation for twenty-four 
hours, unless special accuracy is required, and, as a rule, it is suffi- 
cient to place a few drops of the staining fluid upon the cover-glass 
and to boil this for a few seconds over the free flame, when the 
specimen is further treated as described. In this manner excellent 
results may be obtained in a few minutes. 

Stained according to one of these methods, the bacilli appear as 
rods measuring about 3 ft to 4 u in length by 0.3 u. to 0.5 fi in 
breadth (Plate XIV., Fig. 1). Usually they are not swollen at 
their extremities, but simply rounded off. They occur as homo- 
geneous rods or may present within their stained bodies small round 
or ovoid granules, placed end to end, which do not stain. They 
may also have a straight or a curved form, or the bacillus may 
appear to be doubled upon itself in the form of the letter S. The 
small hyaline bodies in the bacilli have been regarded as spores. 

The number of bacilli which may be found in a sputum varies 
greatly, and while in general it may be said that it is in direct ratio 
to the intensity of the disease, and may thus be considered as of 
some prognostic value, too much reliance should not be placed upon 
this statement, as in acute miliary tuberculosis, and in cases that 
have gone to the formation of cavities, the number may be very 
small or they may be altogether absent. In an incipient case, on the 
other hand, in a little mucoid sputum the number may be very large. 

Of the variations in number and form of the tubercle bacilli 
during treatment with Koch's tuberculin it is unnecessary to speak 
at this place, as the prognostic significance attaching to such varia- 
tions is questionable. 

The Diplococcus Pneumoniae. — In doubtful cases the sputum may 
be examined for the Diplococcus pneumoniae, and it may be accepted 
at the present time that its presence in a given case, providing that 
the clinical history and the physical signs point to a pneumonia, 
renders the diagnosis of acute croupous pneumonia very probable. 

Method. — Cover-glass specimens, prepared as indicated above, 



288 THE SPUTUM. 

are placed for one or two minutes in a 1 per cent, solution of acetic 
acid : they are then removed, the excess of acetic acid is drawn off 
by means of a pipette, when they are allowed to dry in the air : they 
are subsequently placed for several seconds in saturated anilin-water 
and gentian-violet solution, washed in water, and examined. Rod- 
shaped diplococci (Plate XIV., Fig. 2), surrounded by a capsule, 
which latter is considered the characteristic feature of this organ- 
ism, will be seen in cases of acute croupous pneumonia. 1 

The bacillus of influenza has already been considered in Chapter 
I. (page 122). In the sputum it is frequently associated with pyo- 
genic cocci and pnenmococci. 

In whooping-cough protozoa have been observed by Deichler and 
Ivurloff ; their observations have not been confirmed, however, and 
other observers attribute the disease to the presence of bacteria. 
Among these may be mentioned Affanasiew, Ritter. C'zaplewski, 
Hensel, Koplik, and others. All these inve-tigators claim to have 
isolated from the sputum of whooping-cough a micro-organism, 
which they regard as the cause of the di-ease. Whether or not 
Alianasiew's bacillus is idemieal with Ritter s diplococcus and with 
the pole-bacillus of Czaplewski, Hensel. and Koplik 2 is. however, 
not clear. Koplik's organism is extremely minute, measuring from 
0.8 fi to 1.7 fi in length by 0.3 a to 0.4 a in breadth. AVhen 
stained with Loftier' s blue it has a finely punctate appearance, like 
the diphtheria bacillus. In pure culture it is not decolorized by 
Gram's method. It is anaerobic as well as aerobic, and is apparently 
not motile. To isolate it from the sputum, it is best to obtain some 
of the grayisL-^vhite pellets which are expectorated during the con- 
vulsive stage. In these, small particles will be seen, resembling 
scales of dandruff. Such particles are isolated and planted first on 
hvdrocele fluid, in order to obtain the crude culture. Later the 
organism may be grown in bouillon, on agar, gelatin, etc. On 
Loffler's serum a whitish growth is obtained which closely simulates 
that of the diphtheria bacillus. The organism is pathogenic for 
mice, particularly after intraperitoneal inoculation, but it does not 
produce whooping-cough in the lower animals. 

The Smegma Bacillus. — In a few isolated cases the smegma bacil- 
lus has beeD encountered in the sputum, and, as I have already 
stated, the same organism may normally be present in the saliva, 
the coating of the tongue, the tartar of the teeth, etc. Like the 
tubercle bacillus, it resists the decolorizing action of acids when 
once stained, and may hence be confounded with it unless special 
precautions are observed (page 285). 

1 Frankel. Zeit. f. kliu. Med.. 15S6. vol. ii. p. 437. Weiehselbaurn. Wien. med. 
Wock., 1886, vol. xxxix. pp. 1301. 1339. 1367. 

2 E. Czaplewski u. E. Hensel. "Bacterid. Untersuckungen bei Keuckkusten," 
Deutseh. med. Woeh., 1-97. p. 586. H. Koplik. " Tke Bacteriology of Pertussis," 
Johns Hopkins Hosp. Bull.. 1698, p. 79. 



MICROSCOPICAL EXAMINATION. 289 

Rabinowitch } recently succeeded in cultivating from the spu- 
tum of a case of pulmonary gangrene an organism which is 

either identical with the smegma bacillus or closely allied to it; 
she idves the following account of its cultural characteristics: on 
glycerin-agar, after twenty-four to forty-eight hours the organism 

forms errayish-white, lustrous colonies of the size of the head of a 
pin, which gradually coalesce to a whitish, cream-like coating. On 
further growth the lustre disappears, the surface appears dry, the 
coating becomes wrinkled and assumes a yellowish color. Still later, 
when kept at the temperature of the room it turns to a deep orange. 
The organism is non-motile. It occurs in the form of little rods, 
which in older cultures manifest a tendency to the formation of 
long threads. In gelatin stab-cultures small colonies appear along 
the line of the puncture, which are separated from each other. On 
the surface a thickish, white, lustrous coating develops, which gradu- 
ally turns orange. The gelatin is not liquefied. On potato the 
cultures form a moist, gray coating after two or three days. Bouil- 
lon remains clear, but on the surface a wrinkled membrane appears ; 
at the same time a disagreeable odor develops, and a marked indol 
reaction is then obtained. When injected as such the organism was 
not pathogenic for guinea-pigs, while inoculation together with ster- 
ile butter produced changes identical with those obtained by the 
sain 9 observer in the case of an acid-resisting bacillus wdiich has 
repeatedly been found in butter. Unlike Pappenheim's organism, 
the bacillus which was isolated by Rabinowitch was not decolorized 
by Pappenheim's method. Nevertheless, she regards the two as 
identical, and looks upon similar acid-resisting bacilli which have 
be3n obtained from butter, manure, and various grasses, as closely 
related organisms. 

Actinomycosis of the lungs may at times be diagnosed from the 
presence of the characteristic granules and thread-like formations in 
the sputum. In America the disease is very rare. 

The organism in question (Fig. 77) probably belongs to the 
species cladothrix, occupying a unique position among the patho- 
genic bacteria. Infection in man and animals (cattle and pigs) 
p >ssibly occurs through ears of barley or rye, a supposition with 
which the observation that the disease frequently begins in the 
autumnal months accords. 

In the pus derived from ulcerating actinomycotic tumors, in the 
sputum in cases of pulmonary actinomycosis, and also in the feces 
when the disease has attacked the intestines, yellow granules 
will be observed, measuring from 0.5 to "2 mm. in diameter. If 
such a granule is examined microscopically, slight pressure being 
applied to the cover-glass, it will be seen to consist of numerous 

1 L. Rabinowitch, " Refund v. saurefesten tuberkelbacillenahnlichen Bakterien bei 
Lungengangran," Deutech. med. Woch., 1900, No. 1<>. 

19 



290 



THE SPUTUM. 



threads which radiate from a centre in a fan-like manner and 
present clnb-shaped extremities. 

The organism may be demonstrated in the following manner : 
dried cover-glass preparations are stained for five to ten minutes 
with a saturated anilin-water and gentian-violet mixture (see page 
146), when they are rinsed in normal salt-solution, dried between 
filter-paper, and transferred for two or three minutes to a solution 
of iodo-potassic iodide (1 : 100 or 1 : 50). They are then again 
dried between layers of filter-paper, decolorized in xylol-anilin oil 

Fig. 77. 





Actinomyces. (Musses.) 

(1 : 2), washed in xylol, and mounted in balsam. The mycelium 
assumes a dark-blue color. 1 

Non-pathogenic Organisms. — Of the non-pathogenic micro- 
organisms which may be observed in sputa little is known. 

Oidium albicans may be seen in children, and is usually derived 
from the mouth. 

Of other fungi which are occasionally observed, there may be 
mentioned the Aspergillus fumigatus and Mucor corymbifer. Sac- 
charomyces has been seen in pus from pulmonary abscesses. Sar- 
cina pulmonalis has been found at times, and especially in the 
so-called mycotic bronchial props occurring in putrid bronchitis. 
They are usually smaller than the Sarcina? ventrieuli, but larger 
than those observed in the urine ; they present the characteristic 
form of the latter. Various other bacilli and micrococci, in addi- 
tion to those mentioned, are also found in the sputa in large num- 
bers, but have not been closely studied, excepting the pus-organisms, 
which may almost always be demonstrated. 

Crystals. — Of crystals which may occur in sputa, it will be neces- 
sary to consider briefly the crystals of Charcot-Leyden, hseniatoidin, 



1 E. Paltauf. Sitzuugsber. d. K. K. G.sellsch. d. Aerzte Wien, 1886. 



MICROSi -<>ri< '. I L KXAMIX. I TION. 2 ( J 1 

cholesterin, margarin, tyrosin, calcium oxalate, and triple phos- 
phates. 

Charcot-Leyden Crystals. 1 — Those crystals were discovered in the 
sputa of patients suffering from bronchial asthma, and were supposed 
to stand in a causative relation to the disease. This view, however, 
has been disproved, and it is now known that they may occur in 
other diseases as well. But while their presence is almost constant 
in true bronchial asthma at a time when Curschmann's spirals can 
also be demonstrated in the sputa, they are only exceptionally met 
with in other diseases, such as acute and chronic bronchitis, phthisis, 
etc. They were formerly regarded as identical with Bottcher's 
sperma crysbcdSy but modern research has shown that this is not the 
case. They are straight hexagonal double pyramids, and appear 
under the microscope as flattened needles of variable size (Fig. 71). 
Some attain a length of from 40 fi to 60 ft, while others are scarcely 
visible even with a comparatively high power of the microscope. 
They show a feeble, positive double refraction, and have but one 
optical axis, while the sperma crystals are biaxial and strongly 
d mble refracting. Their behavior to solvents is essentially the 
same as that of the sperma crystals, but they differ from these in 
their insolubility in formol. They are colored yellow with Florence's 
reagent, while the sperma crystals are stained a bluish black. Very 
curiously the appearance of Charcot-Leyden crystals is closely asso- 
ciated with the presence of eosinophilic leucocytes, and they have 
hence not inaptly been termed leucocytio crystals. In true bron- 
chial asthma it is not uncommon to find microscopical preparations 
of the sputum literally studded with eosinophilic leucocytes and free 
granules. Outside the sputum they are also found in the blood in 
myelogenous leukaemia, and in the stools in association with animal 
parasites. They readily form in both normal and abnormal red 
bone-marrow, and excellent specimens may be obtained for purposes 
of demonstration if a piece of a rib is allowed to remain exposed to 
the air for a few r days. The marrow then usually contains large 
numbers. The crystals also form in decomposing viscera in general, 
and at times form a complete covering of old anatomical prepara- 
tions. Their occurrence may indeed be regarded as evidence of 
retrogressive changes in the cellular elements of any organ. Of 
the relation which they bear to the eosinophilic leucocytes, with 
which they are so constantly associated, nothing whatever is known. 

Haematoidin crystals may be observed in the sputa following ex- 
travasations of blood into the lung. They frequently occur in the 
form of ruby-red columns or needles (Plate I., Fig. 2); amorphous 
granules, however, are also seen, enclosed in the bodies of leucocytes, 

1 Leyden, Virehow's Archiv, 1872, vol.liv.p. 324. Schreiner, Liebig's Annul., 1878, 

vol. cxciv. p. 68. (dim. Centralbl. f. allg. Path. u. path. Auat., vol. x. p. 940. Brown, 
Phila. Med. Jour., Is98, p. 1076. 



292 THE SPUTUM. 

in which case they are probably always indicative of a previous 
hemorrhage, while the needles are generally observed when an ab- 
scess or empyema has perforated into the Jungs. The substance is 
derived from blood-pigment, and is now known to be identical 
with bilirubin. 

Cholesterin crystals are at times seen in the sputa in cases of 
phthisis, pulmonary abscess, and, in general, whenever old accumula- 
tions of pus have entered the lung from a neighboring organ. They 
are readily recognized by their characteristic form and chemical 
properties (see Feces, page 218). 

Fatty acid crystals are frequently observed in cases of putrid bron- 
chitis and gangrene of the lung, and also in cases of bronchiectasis 
and phthisis. They occur in the form of single needles or groups 
of needles, which are long and pointed. They are easily soluble in 
ether and hot alcohol ; insoluble in water and acids. Chemically, 
they are probably composed of the higher fatty acids, such as pal- 
mitic and stearic acids. 

Tyrosin crystals have been observed in cases of putrid bronchitis, 
perforating empyema, etc. Leucin is likewise probably always pres- 
ent, occurring in the form of highly refractive globules. For the 
recognition of these bodies, particularly of tyrosin, a chemical 
examination should always be made, as crystals of the soaps of 
fatty acids have frequently been mistaken for those of tyrosin 
(see Urine). 

Oxalate of calcium crystals are rarely seen. Fiirbringer observed 
them in large numbers in a case of diabetes, and Unger found them 
in a case of asthma. They are readily recognized by their envelope- 
form, but they occur also in amorphous masses. They are soluble 
in mineral acids ; insoluble in water, alkalies, organic acids, alcohol, 
and ether. 

Triple phosphate crystals also are rarely seen, but may occur in 
cases of perforating abscesses, etc. They are recognized by their 
coffin-lid shape and the readiness with which they dissolve in acetic 
acid. 

CHEMISTRY OF THE SPUTUM. 

In addition to the substances described, sputum contains certain 
albumins, volatile fatty acids, glycogen, ferments, and various inor- 
ganic salts. 

Among the albumins which have been observed in sputa may be 
mentioned serum-albumin, and especially mucin, which is often pres- 
ent in large amounts. In pneumonic and purulent sputa albumoses 
also have been found. 

In order to demonstrate the presence of serum-albumin the sputa 
are treated with dilute acetic acid, when the nitrate is tested with 
potassium ferrocyanide, as described in the chapter on Urine. 



THE SPUTA L\ VARIOUS DISEASES. 293 

Serum-albumiii is, of course, found in notable quantities in cases 
of oedema of the lungs. 

The volatile fatty acids contained in sputa may be obtained by 
diluting with water, acidifying with phosphoric acid, and distilling, 

when the distillate is further examined as described in the chapter 
on Feces. Acetic, butyric, propionic, and capronic acid has been 
found. 

The fats and fixed fatty acids are extracted from the residue with 
ether, and shaken with a solution of sodium carbonate in order to 
transform them into their sodium salts, when the ether is decanted 
and evaporated, leaving the soaps behind. 

Glycogen has repeatedly been demonstrated in sputa, and may be 
detected by Ehrlich's method (see page 52). 

The sputa of gangrene of the lung and putrid bronchitis have been 
shown to contain a ferment resembling trypsin. In order to test for 
this ferment, the sputa are extracted with glycerin ; the examination 
is then continued as described in the chapter on the Examination 
of Cystic Contents. 

The myelin granules, as I have already indicated, consist largely 
of protagon, lecithin, and cholesterin. 

The following are the inorganic salts which may be demonstrated 
in the sputum : sodium and magnesium chloride, phosphates of the 
alkalies and the alkaline earths (viz., calcium and magnesium), cal- 
cium and sodium sulphate and carbonate, phosphate of iron, and 
silicates. 

THE SPUTA IN VARIOUS DISEASES. 

Acute Bronchitis. — In the beginning of the disease the expecto- 
ration is small in amount, transparent, and contains very few cellular 
elements, constituting the so-called sjjutum crudum of the ancients. 
Microscopically, there is evidence of the existence of a desquamative 
process extending toward the pulmonary alveoli to a greater or less 
extent, and especially implicating the bronchi and trachea. Epithelial 
cells of various forms are found, and are probably derived from cells 
which were originally ciliated. Ciliated cells may occasionally be 
observed in perfectly fresh specimens, but are usually absent. Leu- 
cocytes in small numbers and alveolar cells are also seen. The 
presence of a few red blood-corpuscles is a common occurrence, and 
is probably due to rupture of a capillary blood-vessel. Later on, 
the sputa become more abundant, opaque, and assume a yellow color 
tending to green, owing to an increase in the number of leucocytes, 
while the other cellular elements diminish in number. 

Chronic Bronchitis. — The amount and consistence of the sputum 
in this condition vary greatly ; it is most abundant in cases of so- 
called bronchorrlKea, in which whole mouthfuls may be expectorated 
at a time. The color is usually a yellowish green, owing to the 



'-:-- THE .^UTUJL 

' --t::- :: z.Z—H-: r ii :■"«- : rr~^-:I^ iz ":_ > -"._- : _ 
tion. Ifieroee^pi us nam ars of micro-organi sms are 

: zzz - fsie: :..." :_ .•:—:. : . _ :_t «■ .: _. ~- z-zzi ':.--• I : :- Lie 

:::ht in :_t :: . _:_ _.:. . . z~ z zz-i - - _. .:...-..._ 

are found ; the latter , however, are not so abundant as in the first 

-: _t : iz . . :::t ": : : :- A : r "" : . .: -" ::. -.: ; . . T ..- 






- then :f a greenish-yellow or brownish color, and 

: _ :_t izi -: : ; - . - ". .:::i:-^ :: ".: ^rz-Wz. —. - — - 
iiv in size from that of a millet-seed to that of a bean. 

lis :f Lm^-T-Si-r . :: - lis: ~iic ::- -fzilj --r-m. M: r - 
n I'-r :: _rSr ir-Z'^~-Z'j.z-'i .riX':i^ :iy-iii_? :: hiiI'Mit.— 
\_ ■_ -- L . :t ml "•:-_.-- :".-■ : r: . -::: .nil ziii - 
tasmatoidin, are found. The greenish or brownish material 
: : "~.-. : ~ - -•■"" n. : - zz — - - : zzz .._ t_: ~ : _~ -riv- l 

iobm, at times elastic tissue, tatty acid crystals, lat- 

: [zzz •. i-r -t —:■-•- - ;_.;.;-:...- Azi :/ :„ — - :_t 

: ' > liirf- :-.;i_-i:;-i > . :: I i_; 7 .--r :-■: _::::--. ~ 



," 



■ 



^pension. The mper- 

nts all the eharacter- 

iii z ~ ..- ...ti: -. - 
■ :".'"- ■ - _- - " . 

----- Ij . ~ :Lt _ ii- 

- - : : ~ :: :. ~ . :_ - 



■, containing spirals of Cnrschmann, Charcot-Leyden 
a large number of eosinophilic and some basophilic 

f Abscess.— The sputum as long as it is fresh does 
tid odor, and thus diners from that observed in cases 
if the lung. It consists almost entirely of pus ; elastic 
Esent in abundance,, as also a brownish or yellow pig- 
idin. Fragments of lun^-tissue enclosed in a mi - 



THE SPUTA IN VARIOUS DISEASES 29o 

pus have at times been observed, together with fatty acid and choles- 
terin crystals. 

Abscess of the Liver with Perforation into the Lung. — The 
sputa are of a reddish-yellow or reddish-brown color, viscid, muco- 
purulent, and are frequently discharged in large amounts. Micro- 
scopically, pus-corpuscles, red blood-corpuscles, pigmented alveolar 
cells (often undergoing tatty degeneration), as well as elastic tissue 
and granular detritus, are found. The presence of actively moving 
amoebae i-. <>f course, most important from a diagnostic point of view, 
ami is absolutely pathognomonic. Liver-cells, pieces of echinococcus- 
membranes, and booklets may be observed in other cases. 

Pneumonia. — During the first and third stages a simple catarrhal 
sputum is observed which does not present any special characteristics. 
During the secoud stage, however — L c, that of hepatization — the 
sputum is usually quite characteristic. Its color is then reddish- 
brown — the classical rust-colored expectoration. The sputum at the 
same time is generally so tenacious that the spit-cup may actually be 
inverted without losing a drop of its contents. Microscopically, the 
following elements may be found : red corpuscles (to the presence 
of these the reddish color is in part due) ; at times, however, only a 
small number is observed, when the color is referable to haemoglo- 
bin which has been dissolved out from the corpuscles. Leucocytes 
are always present in considerable numbers. Fibrinous casts of the 
finer bronchioles may also be seen, and may, in fact, be visible with 
the naked eye. Alveolar epithelial cells, often loaded with granules 
of pigment, fat, and myelin, as well as others derived from the 
larger bronchi and the trachea, are seen. Should abscess of the lung 
or gangrene complicate the case, the elements described above under 
these headings will be found in addition, the presence of elastic 
tissue being, of course, the most important. 

Note may be taken at the same time of the occurrence of 
pneumococcal bearing in mind, however, that their presence is not 
absolutely pathognomonic. In doubtful cases, as indicated, their 
presence may be regarded as pointing to croupous pneumonia, 
providing that the clinical history and the physical signs arc in 
accord. 

Phthisis Pulmonalis. — The appearance of the sputum in phthisis 
offers nothing that is characteristic, and is dependent upon the stage 
of the disease, it- extent, the existence of complications, etc. In a 
general way it may be said that the sputa in incipient cases are 
usually -mall in amount, of a grayish-yellow color, and tenacious, 
the amount increasing gradually as the disease progresses, the largest 
quantities at tin- stage being expectorated in the morning upon 
rising. When well advanced, nummular sputa are seen. 

The macroscopical examination of the sputa of tubercular patient- 
offers no characteristic features, the elements found being practically 



296 THE SPUTUM. 

the same as those observed in cases of simple chronic bronchitis, 
with one exception — i. e., the occasional admixture of blood, which is 
usually visible with the naked eye, but may vary greatly in amount. 
On the one hand, small specks or streaks of blood may thus be 
observed ; while, on the other hand, the sputa may consist almost 
entirely of blood. The color of the sputum, of course, is influenced 
largely by the amount of blood present and the length of time that 
it has remained in the lungs, and varies from a bright red to a 
dirty brown. In cases in which a considerable hemorrhage has 
taken place it is necessary to exclude every other source before 
attributing the hemorrhage to a pulmonary origin, and in case of 
rupture of an aneurism, or long-continued hypersemic conditions of 
the lungs, so frequently observed in cases of heart-disease, in hemor- 
rhage of gastric origin, and in hemorrhage from the mouth or pharynx, 
it may at times be difficult to determine the source of the blood. 

The diagnosis of phthisis is thus altogether dependent upon a 
microscopical examination, and, above all, upon the demonstration 
of tubercle bacilli and elastic tissue, which have both been considered 
in detail. In addition, leucocytes, alveolar epithelial cells, hsema- 
toidin-crystals and granules are met with, which latter may be 
present in large numbers if a hemorrhage has occurred some time 
before. If the process has gone on to the formation of cavities, 
various constituents are also observed which are found when putre- 
factive processes take place in the lung. 

(Edema of the Lungs. — The sputa are abundant, thin, liquid, 
and frothy, the color of the foam varying from white to a dirty 
reddish-brown. Chemically, such sputa consist almost entirely of 
transuded serum, and are hence particularly rich in serum-albumin. 
Microscopically, only a small number of leucocytes and a variable 
number of red blood-corpuscles are found, the number of the latter, 
however, being scarcely large enough to account for the red color, 
which v. Jaksch ascribes to the presence of methsemoglobin. 

Heart-disease. — The sputa observed in chronic bronchitis the 
result of chronic heart-disease are characterized by the presence of 
so-called u heart-disease cells " — i. e., alveolar epithelial cells con- 
taining numerous hsematoidin-granules (Plate XIV., Fig. 3). If, 
in consequence of the existence of chronic heart-disease hemorrhagic 
infarcts have occurred in the lungs, the patient may at times expec- 
torate numerous masses of a markedly red color, while later on — 
i. e., after several days — they assume a brownish-red appearance, the 
sputum then presenting the characteristics noted some time after a 
hemorrhage. 

The Pneumoconioses. — Among the pneumoconioses, anthracosis, 
siderosis, chalicosis, and stycosis may be briefly considered. These 
conditions are interesting not only from a physiological, but also 
from a pathological standpoint. 



THE SPUTA IN VARIOUS DISEASES. 297 

Anthracosis. — To some extent particles of carbon may be found 
in the sputum of almost every individual, and especially in smokers. 
The expectoration in such eases is of a pearl-gray color, and is 
brought up in larger or smaller masses, especially in the morning 
upon rising. Larger amounts are noted in miners and in those 
who are brought into close contact with coal-dust. Microscopically, 
particles of carbon and epithelial cells, especially of the alveolar 
type, as well as leucocytes loaded with the pigment, are seen. 

Siderosis. — In siderosis the sputum presents a brownish-black 
color and contains cells enclosing particles of ferric oxide. These 
may be readily recognized by treating the preparation with a drop 
of ammonium sulphide or potassium ferrocyanide solution in the 
presence of hydrochloric acid, when a black color on the one hand 
or a blue color on the other is obtained in the presence of iron. 

Chalicosis. — In chalicosis silicates are found in the sputa. 1 

Stycosis. — This condition was first described by A. Robin in a 
man, aged seventy, who from his seventeenth year suffered from 
cough and frequent attacks of diarrhoea, and whose condition at 
various times had been diagnosed as phthisis pulmonalis et intes- 
tinarum, although tubercle bacilli could not be demonstrated. The 
patient died from acute pericarditis complicating an attack of acute 
mono-articular rheumatism. Post mortem the lungs were found 
perfectly normal ; the bronchial and anterior mediastinal glands, as 
well as the mesenteric glands, however, were completely solidified 
and composed almost wholly of calcium sulphate. The man, it was 
then found, had been working in plaster of Paris all his life, and 
the symptoms observed — viz., cough, expectoration, and diarrhoea — 
Robin is inclined to attribute to the pressure of the solidified glands 
upon the bronchi and intestines. 

1 Betts, "Chalicosis Pulrnouum," Jour. Am. Med. Assoc, 1900, No. 2. 



CHAPTER VII. 

THE URINE. 

GENERAL CONSIDERATIONS. 

This is not the place to enter into a discussion of the various 
hypotheses which have been advanced to explain the manner in 
which waste-material is removed from the body through the kidneys. 
It will suffice to state that while the water and mineral constituents 
of the urine in part at least undoubtedly pass into the uriniferous 
tubules by a process of transudation, a selective glandular activity 
of the cells lining the convoluted tubules and the loop of Henle 
appears to be necessary for the elimination of the most important 
organic constituents. 

As the physical characteristics of the urine, as well as its chemi- 
cal composition, are influenced not only by the age and sex of the 
individual, but also by the character of the food ingested, the proc- 
ess of digestion, exercise, climate, temperature, race, etc., it is 
apparent that a quantitative analysis of any one urine, or even 
average figures, can give only an approximate idea of its composi- 
tion. The reader is accordingly referred for information to the 
special paragraphs concerning the variations in the individual con- 
stituents observed in health. It is important, however, to note 
that, notwithstanding the fairly wide variations here observed, the 
composition of the blood, as pointed out in a previous chapter, 
remains quite constant, showing the perfect manner in which the 
nervous system through the kidneys guards against an undue accu- 
mulation of what may be termed normal waste-products in the 
blood, and in virtue of which abnormal substances are also imme- 
diately eliminated. Moreover, as will be pointed out later on, a 
perfect mechanism appears to exist which prevents an undue accu- 
mulation of material in the blood that can hardly be regarded as 
waste. The presence of an amount of sugar in the blood exceeding 
6 pro mille, for example, appears to be invariably followed by gluco- 
suria, and the introduction of excessive calamities of sodium chloride 
similarly and almost immediately leads to an elimination of the 



excess. 



>98 



GENERAL CHARACTERISTICS OF THE URINE. 299 

GENERAL CHARACTERISTICS OF THE URINE. 

General Appearance. 

Normal urine, just voided at an ordinary temperature, is either 
perfectly clear or but faintly cloudy, owing to the fact that the acid 
and normal salts present are all soluble in water. It may be stated, 
as a general rule, that whenever a urine freshly passed presents a 
distinct cloudiness some abnormality exists. 

When allowed to stand for a time a light cloud develops, 
which gradually settles to the bottom, constituting the so-called 
nubecula of the ancients. Examined under the microscope this is 
found to contain a few round, granular cells, somewhat larger than 
normal leucocytes, the so-called mucous corpuscles, and a few pave- 
ment-epithelial cells, derived from the bladder or genital organs. 
Chemically the nubecula probably consists of traces of mucus. 

When kept for twenty-four hours at an ordinary temperature 
crystals of uric acid are frequently observed in addition to the 
above elements, usually presenting the so-called whetstone-form. 
If, however, the temperature at which the urine is kept approaches 
the freezing-point, the entire volume becomes cloudy, owing to pre- 
cipitation of acid urates, as these are much less soluble in cold than 
in warm water ; on standing they gradually settle to the bottom of 
the vessel, and form what is known as a sediment, while the super- 
natant fluid again becomes clear. 

If kept still longer exposed to the air, at the temperature of the 
room, the entire volume of urine again becomes cloudy, owing to a 
diminution of its normal acidity, the result being a precipitation of 
ammonio-magnesium phosphate, calcium phosphate, and still later, 
when the urine has become alkaline, of ammonium urate. 

Gradually a heavy sediment, containing these salts in addition to 
the constituents of the primitive nubecula, forms at the bottom of 
the vessel; the supernatant fluid, however, remains cloudy. On 
microscopical examination it will be seen that this cloudiness is due 
to the presence of enormous numbers of bacteria. 

The changes which take place in a normal urine when allowed 
to stand at ordinary temperature may be tabulated as follows : 

(1) Urine clear, no sediment — reaction acid. 

(2) Urine slightly cloudy, owing to development of the nubecula 

— reaction acid. 

v , , j MUCOUS corpuscles, 

nubecula | Pavement-epithelial cells. 

(3) Urine clear, the nubecula has settled — reaction acid. 

f Mucous corpuscles, 

„ .. | Epithelial cells, 

Sediment Trie acid crystals, 

I A few bacteria. 



300 THE URINE. 

(4) Urine cloudy, owing to the precipitation of phosphates — 

reaction faintly acid. 

(5) Urine cloudy, owing to the presence of bacteria — reaction 

alkaline. 

f Bacteria, 

Mucous corpuscles, 
Epithelial cells, 
Triple phosphates, 
Tri-calcium phosphate, 
Ammonium urate. 



Sediment 



Color. 

The color of normal urine may vary from a very light yellow to 
a brownish red, the particular shade depending essentially upon the 
specific gravity, becoming lighter with a diminishing, and darker 
with an increasing density. Pathologically the same rule holds 
good, except in diabetes, in which a very high specific gravity is gen- 
erally associated with a very light color. The reaction of the urine 
also exerts a marked influence upon its color, an acid urine being 
more highly colored than an alkaline urine, which can be readily 
demonstrated by allowing a specimen of acid urine to become alka- 
line, and by treating an alkaline urine with dilute hydrochloric or 
acetic acid. At the same time it may be said that every urine 
darkens slightly on standing, the reaction remaining acid. 

The various shades observed in normal urines may be grouped 
under the following headings : 

1. Pale urines vary from a faint yellow to a straw color. 

"2. Normally colored urines are of a golden or an amber vellow. 

3. Highly colored urines present a reddish-yellow to a red color. 

4. Dark urines vary between brownish red and reddish brown. 
As these shades may occur in both normal and pathological urines, 

definite conclusions cannot, as a rule, be drawn from mere inspection. 
A very pale urine indicates simply an excess of water, which may 
be normal, but may also occur in such diseases as chronic interstitial 
nephritis, diabetes mellitus, diabetes insipidus, hysteria, and the 
various anaemias : it is further seen during convalescence from acute 
febrile diseases, while a highly colored urine, though also occurring 
in health, may indicate the existence of a febrile process. It may 
be stated, as a general rule, that a pale urine always excludes the 
existence of a febrile disease of any severity, and that the continued 
secretion of a very pale urine is usually associated with a certain 
degree of ansemia. 

The normal color of the urine is probably owing to the presence 
of several pigments, which are most likely closely related to each 
other and to hsematin. 

In addition to these colors others may be observed at times which 
are either pathological or accidental — i. t., due to the presence of cer- 



GENERAL CHARACTERISTICS OF THE URINE. 301 

tain drugs. The former arc, on the whole, of greater importance to 
the physician than those mentioned above, as more definite conclu- 
sions can be drawn from their presence. Most important among 
such pathological pigments are those due : 

1. To the presence of blood-coloring matter. The color in such 
cases may vary from a bright carmin to a jet black, the exact shade 
depending upon the quantity of blood-coloring matter present, upon 
changes that the blood may have undergone either before or after 
being passed, and also upon the presence of the pigment in solution 
or contained in red corpuscles. 

2. Those due to the presence of biliary coloring matter. The 
color here varies from a greenish yellow to a greenish brown. 

3. A milky-colored urine is observed in cases of chyluria. 
Among the accidental abnormalities in color, on the other hand, 

are those due to the presence of substances like carbolic acid and its 
congeners, santonin, etc. 

As the recognition of the causes of such alterations, normal, 
pathological, and accidental, largely depends upon a more detailed 
study of the individual pigments, this subject will be dealt with 
more fully further on (see Pigments and Chromogens). 

Odor. 

The odor of the urine is usually of little significance. Normally 
it resembles that of bouillon, and in some cases that of oysters ; it 
is probably due to the presence of several volatile acids. The odor 
of urines undergoing decomposition is characteristic and has been 
termed " the urinous odor of urine," an ill-chosen term, as this odor 
is always indicative of an abnormal condition. 

The ingestion of asparagus, onions, oil of turpentine, etc., pro- 
duces a characteristic odor which is of no significance. 

Consistence. 

Urine, while normally fluid and but slightly viscid, may in dis- 
ease acquire a marked degree of viscidity, which becomes especially 
apparent upon attempting its filtration ; the liquid passes through 
the paper with more and more difficulty, and finally clogs its 
pores altogether. 

Quantity. 

The quantity of the urine is normally subject to great variations, 
the amount eliminated in the twenty-four hours being influenced by 
that of the fluid ingested, the nature and quantity of the food, the 
process of digestion, the blood-pressure, the surrounding tempera- 
ture, sleep, exercise, body- weight, sex, age, etc. 

It is easy to understand, then, why figures given by different 



: _ r^z ITEISK 

observers in different countries should vary considerably. Salkow- 
ski, in Germany, thus gives 1500 to 1700 cc as the normal 
amount ; v. Jaksch, in Austria. 1500 to 2000 cc ; Landois and 
fezziz^;. iz Ezzizzz. i: iz z: 1-: z z: 'r-zfr. iz Jzzlz. 1_" " 
to 1300 ce. In :it United States - have : »nd an verage secre- 
tion of from 1000 to 1200 cc. in the adult male, and 900 to 
1000 cc in the adult female It is thus seen that die secretion 
:: :.::: i~ _:-:--: iz tzzzzzz ■ izi Az~zziz. ~~~l-~:- :z ::-:-:I~-~-r:i:z: 
and ingestion of liquids are greater than in England, France, and 

Children pass less, but relatively more (considering their body- 

• :::~l - :-- - zzzz: iz-s :_.; . z zzzz, 



urine is voided. The same occurs during repose, more urine being 

-- ::zzzZi . zz z rzzzx z . _t::: .:-« zzzz z ~--. zz^zz: zz z 
during the day. 

The amount of urine secreted in the different hours of the day 
varies greatly, reaching its maximum a few hours after meals. It 

:irzz —- :: ~zz: \ z.z : z i :-; :zrS izs i --zsz t zz: iz zz zzz z z;~ 
of the night, after which it begins to rise rapidly until 2 or 3 

The ingestion of large amounts of liquid, of course, increases the 
daily amount considerably^ and 3000 cc may be passed under such 
conditions by an individual in good health, while it may decrease to 
MM) or 900 cc when but little liquid is taken. 

Azz-r zz izzz-zzz : zzzz'z - : z :, ::■ z. :_r --zrz: :z :: zz:z-> is 
teoiporarily diminished. 

Water containing no salts possesses distinctly diuretic properties, 
as do also beer, wine, coffee, tea, etc 

- zz:sz izz n z z . ._ zzzz- zz zzz zz 

broom, spirit of nitrous ether,, juniper, urea, etc 

Pathologically the amount of urine varies within wide limits. Iz 
a given case, moreover, it m_z be exceedingly zzzz: z letennine 
whether or not the secretion is within physiological limit- 
general rule, whenever less than 500 cc or more than 3000 cc are 
passed some abnormal condition exists, providing all other causes 
which might lead to the secretion of such an amount can be elimi- 
nated. 

Clinically we speak of polyuria and oliguria. 

Polyuria. — Polyuria is observed in many diseases, and is present 
under such varied conditions that a classification is only warrant- 
able upon a hypothetical basis, especially as the causative fee: 
concerned in its production are mostly unknown. 

As z«olyuria is almost invariably associated with diabetes mel- 



gexer.il characteristics of the urine. 303 



litiiSj its presence in any case should always excite suspicion and 
lead to a proper examination. The quantity of fluid eliminated in 
diabetes is usually dependent upon the amount invested. The excre- 
tion of a proportionately Large amount of fluid, however, does not 
necessarily follow the ingestion directly, and retention of a Large 
amount may occur; it has been shown, as a matter of fact, that the 
diabetic patient excretes liquids with greater difficulty than the 
health v subject. At the same time it should be borne in mind that 
the polyuria in diabetes is not necessarily continuous, and that 
periods during which a normal or even a subnormal amount of urine 
is observed may alternate with true polyuria. From 2 to 26 or even 
50 liters may be passed within twenty-four hours. Intercurrent dis- 
eases of a febrile character may modify the quantity very materially 
and cause the elimination of a normal or subnormal amount. 

The cause of the polyuria in diabetes mellitus is unknown. The 
ingestion of large amounts of liquids, of course, leads to a cor- 
respondingly large elimination, and the existing polydipsia could, 
hence, be made responsible for the polyuria ; the latter would thus 
be the result of an increased stimulation of the thirst-centre, pos- 
sibly owing to the presence of some abnormal constituent of the 
blood. The polydipsia, however, may also be the result of a pri- 
mary polyuria. 

The polyuria associated with the resorption of large pericardial, 
pleural, ascitic, and subcutaneous effusions is more readily under- 
stood, although the primum mobile may be unknown ; it depends 
in such cases entirely upon the presence of excessive quantities of 
fluid in the bloodvessels. 

A form of polyuria which has been termed " epicritic polyuria " 
is frequently observed during convalescence from acute febrile dis- 
eases, and is of prognostic importance. Its occurrence in a given 
case is regarded by many as a good omen, especially in typhoid 
fever ; still it must not be forgotten that a polyuria may occur 
after subsidence of the fever, and be followed by a considerable 
degree of oliguria, and in some cases may precede death. A polyuria 
of this kind probably always indicates the elimination of waste- 
products which had accumulated in the blood during the course of 
the disease, but it may, at the same time, be due to the presence of 
retained water. 

Second in constancy is the polyuria associated with granular 
atrophy of the kidneys, constituting one of the most important symp- 
toms of the disease. Cases have been reported in which as much as 
10,000 c.c. of urine were secreted in the twenty-tour hours; 20(H) 
to 4000 c.c. represent the usual amount in such cases. Polydipsia 
commonly exists at the same time, and the explanation of the poly- 
uria again becomes a very difficult matter. That generally given 
is based upon the following considerations : 



304 THE UBIMK 

In granular atrophy of the kidneys large tracts of renal paren- 
chyma are destroyed, the result being a diminution in the area of 
glandular material, which in itself would lead to a diminished secre- 
tion of urine. The coexisting cardiac hypertrophy, however, by 
raising the blood-pressure in the kidneys, is supposed to counter- 
balance the renal deficiency and even to lead to an increase in the 
amount of urine. There appears to be some doubt as to the cor- 
rectness of such an explanation, however, as the existence of hyper- 
trophy of the left ventricle in the absence of glandular disease of 
the kidneys by no means leads to a degree of polyuria comparable 
to that observed in this disease. It is possible that while cardiac 
hypertrophy in itself may be one of the causative factors, still 
another may be a vicarious action of the sound glandular elements. 
If such be the correct explanation, the coexisting polydipsia is 
merely secondary. This, however, can only be regarded as an 
hypothesis, and the diminished renal secretion associated with a 
gradually developing cardiac dilatation should not be upheld as 
an absolute proof of its correctness. 

Very curiously, polyuria may occur also in association with mul- 
tiple myelomata of the bones and the presence of Bence Jones' 
albumin in the urine. In one of the cases reported by Hamburger, 1 
and which I had occasion to study in greater detail from a chemical 
point of view, 3500 c.c. were voided in the twenty-four hoars. 
The symptom, however, is not constant. 

Polyuria, furthermore, has been observed in the most diverse 
diseases of the nervous system, both functional and organic. It is 
frequently observed both as a transitory and a permanent symptom 
in cases of hysteria. Large quantities of a very pale urine are 
secreted after the occurrence of severe hysterical seizures, but the 
same may be observed throughout the course of the disease. A 
similar condition is frequently seen in neurasthenia, migraine, chorea, 
and epilepsy. 

Generally speaking, it may be said that a paroxysmal polyuria in 
nervons diseases is associated with functional derangement, while 
a continuous polyuria appears to be connected rather with true 
organic changes. It has been observed in certain cases of tabes, 
cerebrospinal and spinal meningitis, during the first stage of general 
paresis, in association with tumors involving the medulla, the cere- 
bellum, and the spinal cord, in injuries affecting the central nervous 
system, in Basedow's disease, etc. Cases of idiopathic diabetes 
insipidus also should probably be classified under this heading. 
Enormous quantities of urine may be secreted in this disease, which 
are equalled only by cases of diabetes mellitus, and may at times 
reach 43 liters per diem. 

1 L. P. Hamburger. u Two Examples of Bence Jones Albuminosuria associated with 
Multiple Myeloma.'" Johns Hopkins Hosp. Bull., Feb., 1901. 



GEM: HAL CHARACTERISTICS OF THE URINE. 305 

Oliguria. — Oliguria is, on the whole, more frequent than polyuria, 

and is met with in almost all conditions associated with a lowered 
blood-pressure. First in order stand th<»e eases of cardiac disease 
in which compensation has failed, whether the cardiac weakness LS 
primary or occurring secondarily to other diseases — i. c, pulmonary, 
hepatic, and renal. 

The oliguria observed in the so-called continued fevers, notably 
typhoid fever, is probably also referable to cardiac weakness. It 
should be remembered, however, that a larger proportion of water 
is eliminated through the skin and lungs than normally, and that 
a retention of fluids also undoubtedly occurs which is not due to 
cardiac weakness ; still other factors may be concerned in its 
production. 

The oliguria occurring in acute nephritis and in chronic paren- 
chymatous nephritis in all probability depends largely upon mechani- 
cal causes, the increased intra-canalicular resistance in the form of 
desquamated epithelium and tube-casts, as well as the pressure of 
the exudate upon the bloodvessels obstructing the passage of urine, 
while the functional activity of the diseased glandular elements is at 
the same time lowered. Upon mechanical causes, also, depend all 
those cases of oliguria which are associated with the presence of a 
stone or tumor pressing upon a portion of the urinary tract. 

Oliguria may occur as a nervous manifestation in connection with 
puerperal eclampsia, lead colic, hysteria, psychic depression, preced- 
ing and during epileptic seizures, etc. AVhenever there is a diminu- 
tion in the amount of bodily fluids oliguria is also observed ; this is 
particularly marked in cholera and following severe hemorrhage. 

Obstruction to the flow r of blood in the vena cava or liver, lead- 
ing to an increase of venous pressure and a decrease of arterial 
pressure in the kidneys, likewise results in oliguria, as is seen in 
atrophic hepatic cirrhosis, acute yellow atrophy, thrombosis of the 
vena cava anol the renal vein, or in cases in which pressure is 
exerted upon these by tumors, ascitic fluid, etc. 

In any case the oliguria may go on to complete anuria, which 
condition not infrequently precedes death. Anuria may, however, 
also occur independently of a pre-existing oliguria, as in hysteria. 

Specific Gravity. 

Tli<> specific gravity of normal urine varies between 1.015 and 
1.025, corresponding to 1200 to 1500 c.c, viz., the normal amount 
of urine voided in twenty-four hours. Pathologically, a specific 
gravity of 1.002 on the one hand and 1.0(>0 on the other may occur, 
depending upon the amount of solids and fluids present, increasing 
a- the <olids increase, the amount of urine remaining the same, and 
decreasing as the amount of fluid increases, the solids remaining the 

20 



o!"3 THE URINK 

game. The specific gravity is thus an index in a general way of 
the metabolic processes taking place in the body. 

The necessity of determining the specific gravity of the total 
amount of urine voided in a given case, and not that of an individual 
specimen passed during the twenty-four hours, becomes apparent 
upon considering the variations which may occur in the quantity of 
solids and liquids ingested during the day. The ingestion of large 
amounts of water or beer would, of course, result in the pas- age : 
a correspondingly large quantity of urine within the next few hours, 
containing but a small amount of solids, and hence presenting a lc 
specific gravity. From such an observation it would be errone us 
to infer a diminished excretion of solids for the day. as succeeding 
specimens would in all probability be passed presenting a higher 
specific gravity. An observation made upon a specimen taken 
from the collected urine of the twenty-four hours, moreover, can 
only then convey a correct idea if the total quantity is within the 
normal limits. If this should not be the case, the volume of the 
urine passed must first be reduced to the normal and the specif 
gravity then taken. 

Supposing a known quantity of common salt to be dissolved in 
1000 c.c of water, so that the resulting specific gravity is 1.24; by 
doubling the amount of salt and water the specific gravity would 
still remain the same, while the amount of salt would actually be 
twice as large as at first. In order to obtain the specific gravity 
indicating the actual amount of solids present it would be necessary 
to concentrate the fluid to 1000 c.c The specific gravity being 
inverselv proportionate to the amount of fluid secreted, the necessary 
correction is made according to the following formula : 

qd 
Sp.gr. = 

in which Sp. gr. indicates the specific gravity to be determined, q 
the amount of urine actually passed, d the specific gravity observed, 
and JTthe normal amount of urine — L e,, 1200 c.c. 

Ukampfe. — A patient has passed 3000 c.c. of urine in the twenty- 
four hours with a specific gravity of 1.017 ; this is corrected accord- 
ing to the above formula : 

Sp. gr. = 3000 x 17 = 1.042. 

From the specific gravity the amount of solids can be calculated 
with sufficient accuracy for clinical purposes by multiplying the last 
two decimal points by 2, the number obtained indicating the amount 
of solids in 1000 c.c. of urine. 

To illustrate the necessity of either indicating the total amount of 
urine passed within the twenty-four hours, and of taking the specific 



GENERAL CHARACTERISTICS OF THE URINE. 307 

gravity t'roni this collected urine, or of correcting the specific gravity 
as shown above, the following case may be supposed : 

A " specimen " of urine is taken, presenting a specific gravity of 
1.002 ; by multiplying the 2 by 2, the person would be supposed to 

pass 4 grammes of solids in every 1000 c.c. of urine. Had the 
specific gravity been observed in the total amount of urine passed 
in the same twenty-four hours, it would have been found to be 1.012, 
the man having passed 3000 c.c. of urine; by multiplying 12 by 2, 
24 grammes of solids would have represented the amount in every 
1000 c.c. — i. e., 24 X 3 = 72 grammes in toto. The same result 
would have been reached by correcting the specific gravity of 1.012 
for the normal amount of urine. 

The first calculation then would have indicated a considerable 
deficit as compared with the second. 

The following rules for practice may thus be stated : 

1. Whenever the specific gravity only is to be indicated in a uri- 
nary report it should always be the corrected one ; if this is not done, 
the amount of urine should be stated in every case. 

2. The specific gravity should always be taken from a specimen 
of the collected urine of the twenty-four hours, and never from a 
specimen ad libitum. 

From the rule, that the specific gravity of a urine is inversely 
proportionate to the amount of fluid eliminated, it must follow that 
whatever causes produce oliguria will also produce a high specific 
gravity, while all those causes which produce a polyuria will similarly 
produce a low specific gravity, with the following exceptions : 

1. A diminished amount of urine with a lowered specific gravity 
occurs in many chronic diseases and toward the fatal termination of 
acute diseases, indicating a defective elimination of solids. 

2. The same may be observed in certain cases of oedema. 

3. Following copious diarrhoea, vomiting, and sweating. 

4. A high specific gravity is associated with polyuria in diabetes 
mellitus. 

Unfortunately the determination of the specific gravity and the 
solids contained in urines does not furnish as valuable information 
in many cases as would be expected d, priori. This is largely owing 
to the fact that the organic constituents of the urine have a lower 
specific gravity than the inorganic salts, and especially the chlorides, 
which are usually present in considerable amount. It thus not in- 
frequently happens that the nitrogenous constituents are considerably 
increased, while the specific gravity is relatively low, owing to the 
absence or a diminution in the amount of chlorides. In other words, 
while the specific gravity may be regarded as a fair index of the 
total amount of solids excreted, its increase or decrease furnishes no 
information as to the nature of the constituents causing such a 
change. 



308 



THE UEISE. 



Fig 



Determination of the Specific Gravity. — The specific gravity of 
the urine is most conveniently determined by means of a hydrometer 
indicating degrees varying from 1.002 to 1.040. Such instruments, 

constructed especially for the examina- 
tion of urine, are termed urinometers 
(Fig. 78). A good instrument should 
have a stem upon which the individual 
divisions are at least 1.5 mm. apart, and 
each di vision should correspond to 0.5 
degree. 

Urinometers may also be purchased 
which are provided with a thermometer, 
a matter of great convenience. Every 
instrument should be carefully tested by 
comparison with a standard hydrom- 
eter. 

In order to determine the specific 
gravity in a given case a cylindrical ves- 
sel is nearly filled with urine and the 
urinometer slowly introduced, the read- 
ing being taken at the lower meniscus 
as soon as the instrument has come to 
rest. 

Precautions : 1. The urinometer must 
be given ample room, and the read- 
iug should never be taken when the in- 
strument touches the sides of the ves- 
sel, as owing to capillary attraction it 
is otherwise raised, causing the reading 
to be too high. 

2. The instrument must be perfectly 
dry and clean before being used, and 
should never be allowed to "drop" into 
the urine, as otherwise the weight of the 
instrument is increased by adhering 
drops of water, and the reading is too low. 

3. Any foam upon the surface of the urine should first be removed 
by means of a piece of filter-paper, as it interferes with the accuracy 
of the reading ; bubbles of air adhering to the instrument, and 
thereby elevating it, should be carefully removed with a feather. 

4. The specific gravity should always be determined in specimens 
taken from the twenty-four-hour urine, and corrected according to 
the formula given above. 

5. If the quantity of urine is too small to determine its specific 
gravity with a urinometer, the folio wiug method may be advan- 
tageously employed : 




Urinometer 



IMON.) 



GENERAL CIIAHACTFFISTTCS OF THE URINE. 



309 



About 50 e.c. of urine are measured into a small bottle pro- 
vided with a ground-glass stopper, or into a pyknometer like the one 
pictured in Fig. 79, and accurately weighed. The weight of the 

Fio. 79. 




The pyknometer. 

urine divided by its volume gives the specific gravity, which must, 
however, be corrected for the temperature of the urine. If accuracy 
is required, such corrections should be made in every case, as the 
specific gravity increases or decreases by one degree for every three 
degrees C. above or below the point for which the instrument is reg- 
istered, viz., 15° C. According to Bouchardat and Mercier, this 
method is not strictly accurate, and the following table has been 
constructed by which the proper corrections can be readily made : 



Tempera- 


Normal 


Sugar 


Tempera- 


Normal 


Sugar 


ture. 


urine. 


urine. 


ture. 


urine. 


urine. 


0° 


0.9 


1.3 


18° 


0.3 


0.6 


1 


0.9 


1.3 


19 


0.5 


0.8 


2 


0.9 


1.3 


20 


0.9 


1.0 


3 


0.9 


1.3 


21 


0.9 


1.2 


4 


0.9 


1.3 


22 


1.1 


1.4 


5 


0.9 


1.3 


23 


1.3 


1.6 


6 


0.8 


1.2 


24 


1.5 


1.9 


7 


0.8 


1.1 


25 


1.7 


2.2 


8 


0.7 


1.0 


26 


2.0 


2.5 


9 


0.6 


0.9 


27 


2.3 


2.8 


10 


0.5 


0.8 


28 


2.5 


3.1 


11 


0.4 


0.7 


29 


2.7 


3.4 


12 


0.3 


0.G 


30 


3.0 


3.7 


13 


0.2 


0.4 


31 


3.3 


4.0 


14 


0.1 


0.2 


32 


3.6 


4.3 


15 


0.0 


0.0 


33 


3.9 


4.7 


1G 


0.1 


0.2 


34 


42 


5.1 


17 


0.2 


0.4 


35 


4.6 


5.5 



Example. — Supposing the specific gravity to have been 1.030, at 
a temperature of 20° C, it would be necessary to add 0.9 to 1.030, 



310 



THE URIXE. 



making this 1.0309 ; at a temperature of 10° C., it would similarly 
be necessary to subtract 0.5. 

Determination of the Solid Constituents. — As indicated above, 
the amount of solids can be calculated with a degree of accuracy 
sufficient for clinical purposes by multiplying the last two figures of 
the specific gravity by 2 ; the number obtained indicates the amount 
of solids in every 1000 c.c. of urine. If greater accuracy is re- 
quired, the following method may be employed : 

Five c.c. of urine, accurately measured, are placed in a watch- 
crystal containing a little dry sand (sand and crystal having been 
previously weighed) ; this is placed over a dish containing concen- 
trated sulphuric acid, and under the receiver of an air pump which 
has been made perfectly air-tight by thoroughly lubricating the 
ground-glass edge of the bell with mutton tallow and applying the 
bell with a slightly grinding movement to the ground-glass plate. 
The receiver is now exhausted and the urine allowed to remain in 
the vacuum for twenty-four hours, when the bell is again exhausted 
and left, for twenty-four hours longer ; at the end of this time the 
crystal is weighed, the difference between the two weights obtained 
indicating the amount of solids in 5 c.c. of urine, from which the 
percentage and total amount are readily calculated. 

The slight loss of ammonia which results when this method is 
employed scarcely affects the accuracy of the result. 

REACTION. 

The reaction of the twenty-four-hour urine is, as a rule, acid ; 
individual specimens, passed in the course of the same twenty-four 
hours, may be either alkaline, acid, or amphoteric. 

"When a mixture of different acids is brought into contact with 
a mixture of alkalies, the acids combine with the alkalies according 
to the degree of affinity which exists between them and the amount 
present of each. Upon the excess of acids over alkalies, and vice 
versa, depends the resulting reaction. If the alkalies are not suf- 
ficient in amount to saturate the acids, an acid reaction will result, 
while an insufficient amount of acid will give rise to an alkaline 
reaction. The same principle holds good for the acids and alka- 
lies giving rise to the salts present in the urine. As here the 
alkaline substances are not present in sufficient amount to saturate 
the acids, which can readily be seen from the following table, the 
acid reaction of normal urine is explained : 



HC1 


so 3 


P 2 5 K 

1 


Na XH 3 


Ca Mg 


10.1265 
6.3811 


2.3157 
1.3315 


3.0334 
0.9827 


2.5830 
1.5194 


5.4780 
5.4780 


0.5977 
0.8087 


0.0405 
0.0233 


0.0S80 
0.0843 



The figures in the first column indicate the average daily amount 



REACTION. 311 

of the inorganic acids and alkalies present in the urine of twenty- 
four hours, and the figures in the second column their equivalents 
in terms of sodium, that of phosphoric acid having been estimated 
as diaeid sodium phosphate. From this it is seen that the acid 
equivalents, 8.6953, exceed the alkaline equivalents, 7.9137, by 
0.7816 gramme of sodium. There are present then in the urine, in 
addition to the normal salts of the monobasic acids, acid salts and 
especially diaeid sodium phosphate, NaH 2 P0 4 . To the latter the 
acidity of the urine is due. If, on the other hand, the alkalies 
exceed the acids in amount, an alkaline urine will result, which may 
occur physiologically under various conditions. 1 

The so-called amphoteric reaction will be observed when the 
diaeid and neutral sodium phosphates, NaH 2 P0 4 and Na 2 HPO ( , are 
present in a certain definite proportion; the urine. then changes the 
color of red litmus paper to blue, and vice versa.' 2 

A neutral urine is never observed under normal conditions. The 
presence of a free acid, moreover, is not possible, as it would imme- 
diately combine with ammonia, which is constantly being set free in 
thj tissues of the body as ammonium lactate, and is normally trans- 
formed into urea. 3 

The question now arises, How does the acidity of the urine re- 
sult ? and What are the ultimate factors that will produce an alka- 
line and an amphoteric reaction ? 

These are problems which as yet await a final answer. Our 
present ideas, however, may be formulated as follows : In the me- 
tabolism of the body-tissues acids are constantly produced ; chief 
among these is sulphuric acid, which results from albuminous decom- 
position, and hydrochloric acid, which at a certain period of digestion 
is reabsorbed from the stomach. As the alkalinity of the blood is 
due to neutral sodium phosphate and sodium carbonate, these salts 
are attacked by the free acids as soon as they enter the blood, the 
result being the formation of acid salts, and, as the latter diffuse 
more readily through an animal membrane than alkaline salts, the 
secretion of an acid urine from the alkaline blood is in part ex- 
plained. Nevertheless it is impossible to exclude a certain specific 
action on the part of the glandular elements of the kidneys, as 
otherwise the secretion of all glands, supposing this to depend 
upon a process of filtration or diffusion only, would necessarily be 
acid. 

As the alkalinity of the blood increases the acidity of the urine 
d "creases, until finally an alkaline urine results. The degree of the 
alkalinity of the blood, however, depends essentially upon the nature 
of the food and the secretion of the gastric juice, viz., the hydro- 

1 Briickc. Maly's Jahresber., 1887, vol. xvii. p. 189. Ljebig, Annul. <1. Chem. u. 
Pharmakol.. 1-1 i. vol. 1. p. 61. 

2 Heintz. Jour. f. prakt. Chem., 1872, vol. vi. p. J?i. 

3 F. Walters, Arch. f. exper. Path. u. Pharmakol.. 1877, vol. vii. p. 148. 



312 THE URTNE. 

chloric acid. The ingestion of vegetable food, rich in salts of or- 
ganic acids, which become oxidized in the body to the carbonates of 
the alkalies, will result in the passage of an alkaline urine, for the 
alkalies thus formed when absorbed into the blood are more than 
sufficient to neutralize completely all the acids present, and the elimi- 
nation of neutral sodium phosphate alone takes place. In the case 
of animal food the reverse holds good. The alkaline carbonates 
here formed are not sufficient to neutralize the excess of acids, and 
diacid phosphate of sodium is hence eliminated in large quantity. 1 

An amphoteric urine results whenever the elimination of neutral 
and acid sodium phosphate is the same ; such an occurrence is, 
therefore, more or less accidental. 

As the alkalinity of the blood is increased during the secretion 
of the acid gastric juice, it may frequently happen, especially follow- 
ing the ingestion of a large amount of food, that an alkaline urine 
is voided. If this does not take place, the acidity of the urine is at 
least diminished, but increases again during the process of resorp- 
tion of hydrochloric acid and peptones. The statement so generally 
found in text-books, that the urine secreted after a meal is alka- 
line, is not strictly correct ; in a series of observations which I made 
-in this direction an alkaline urine was observed in only 20 per 
cent, of the cases examined. 2 

It may thus be stated that an alkaline urine will result under 
physiological conditions whenever the alkaline salts present in the 
food are sufficient to neutralize all the acids formed, as occurs in the 
case of a vegetable diet, and, furthermore, whenever the period of 
gastric secretion is lengthened. 

If an acid urine is allowed to stand exposed to the air for a cer- 
tain length of time, its degree of acidity gradually diminishes, and 
the reaction finally becomes alkaline. At the same time the urine 
becomes cloudy and deposits a sediment, which consists of ammonio- 
magnesium phosphate, MgNH 4 P0 4 +6H 2 0, neutral calcium phos- 
phate, Ca 3 (P0 4 ) 2 , and still later contains ammonium urate, C 5 H 2 - 
(NH 4 ) 2 N 4 O s , in addition to the constituents of the primitive nubecula 
— i. e., a few mucous corpuscles and pavement epithelial cells. The 
entire volume of urine, moreover, remains cloudy, owing to the 
presence of innumerable bacteria. The odor becomes extremely disa- 
greeable, and distinctly " urinous." In short, " ammoniacal decom- 
position " has occurred. This has been shown to depend upon the 
action of certain bacteria, notably the Micrococcus urea? and the Bac- 
terium urea?, which are present in the air. 3 These organisms cause 
decomposition of the urea found in every urine, with the forma- 
tion of ammonium carbonate, according to the following equations : 

1 E. Salkowski u. J. Munk, Vircbow's Archiv, 1877, vol. lxxvi. p. 500. 

2 Quincke, Zeit. f. klin. Med., vol. vii. 

3 W. Leube, "Ueber die ammoniakalische Harngabrung," Vircbow's Arcbiv, 1885, 
vol. c. p. 555. 



REACTION. 313 

0O(NH,), + 2H,0 = (NHJaOO, 
(NH*),CO a = 2NH a + H 2 + C0 2 . 

It is Dot the bacterium, however, which directly produces the re- 
sult, but a bacterial product, and in this case an enzyme. 

An alkaline urine, the alkalinity of which is not due to ammo- 
niacal fermentation, however, but to other causes, as indicated 
above, may, of course, undergo the same change as an acid urine ; 
but it is necessary to distinguish sharply between these two varieties 
of alkaline urines, as the recognition of the cause of the alkalinity is 
very often most important in diagnosis. The distinction is readily 
made by fastening a piece of sensitive red litmus-paper in the cork 
of the bottle containing the urine. If the alkalinity of the urine is 
due to the presence of ammonia, the litmus-paper will turn blue, but 
soon changes to red when exposed to the air ; while a urine, the 
alkalinity of which is due to the presence of fixed alkalies, will turn 
red litmus-paper blue only ivhen immersed in the urine, the change 
in color at the same time persisting. 

As ammoniacal decomposition can also occur within the urinary 
passages, it is important, whenever an alkaline reaction due to the 
presence of ammonia is observed, to test the urine at once upon being 
voided, or, still better, to procure a portion with a catheter. Such 
urines are frequently seen in cases of cystitis the result of paralysis, 
urethral stricture, gonorrhoea, etc. 

An intensely acid reaction is observed in almost all concentrated 
urines, especially in fevers, in certain diseases of the stomach asso- 
ciated with a diminished or suspended secretion of hydrochloric acid, 
in gout, lithiasis, acute articular rheumatism, chronic Bright' s dis- 
ease, diabetes, leukaemia, scurvy, etc. Whenever a very acid urine 
is secreted for a considerable length of time the possibility of 
renal irritation and the formation of concretions should be borne 
in mind. 

An alkaline urine, the alkalinity of which is not owing to the 
presence of ammonia, but to a fixed alkali, is observed in certain 
cases of debility, especially in the various forms of anaemia, follow- 
ing the resorption of alkaline transudates, the transfusion of blood, 
frequent vomiting, a prolonged cold bath, etc. It may also be due 
to the ingestion of certain drugs, viz., salts of the organic acids and 
alkaline carbonates, the former being transformed into the latter, as 
has been mentioned. An increase in the degree of acidity may 
similarly take place after the ingestion of mineral acids. 

Of interest is the observation of Pick 1 that in twenty-four to 
forty-eight hours after the crisis in pneumonia the urine shows a 
marked decrease in its acidity, becoming neutral or even alkaline. 

1 F. Pick, "The Urine in Pneumonia," Munch, med. Woch., 1S9S, No. 17. 



314 THE URINE. 

This phenomenon, which was observed in thirty-one out of thirty- 
eight eases, persists for a day or a day and a half, and then the 
acidity returns. In all likelihood the change is due to absorption 
of the large amounts of sodium which are present in the exudate. 

An increase in the acidity of the urine upon standing has repeat- 
edly been observed, and is probably due to the formation of new 
acids from pre-existing acid-yielding substances, such as certain 
carbohydrates, alcohol, etc., which have undergone fermentation. 
This phenomenon is frequently observed in diabetic patients. 

A decrease in the acidity of normal urine upon standing, however, 
is the rule, owing to a gradual decomposition of sodium urate by 
the acid sodium phosphate, acid sodium urate, and. later on, uric 
acid resulting, which are thrown down as a sediment in consequence 
of the diminished acidity of the urine, and which, hence, no longer 
influence its reaction. This is shown in the equations : 

1 NaH 2 P0 4 — C-H,Xa 2 >7:>3 = Xa 2 HP0 4 -f C^H 3 NaK 4 O a 
(2) NaEgPQ, + C 3 H 3 XaX i 3 = Xa 2 HP0 4 -f C 5 H 4 NA- 

Determination of the Acidity of the Urine. — The old method 
of titrating a certain amount of urine with a decinormal solution of 
sodium hydrate has been abandoned and replaced by that of Freund. 
This is essentially based upon the observation that the acid reaction 
of the urine is referable exclusively to diacid phosphates. 

Fremiti's Method. 1 — In 50 c.c. of urine the total amount of phos- 
phoric acid is estimated as described on page 331. The result is 
termed T. In a second portion of 50 c.c. the monacid phosphates, 
M 7 are then precipitated with a normal solution of barium chloride — 
i. e. } one containing 122 grammes of the crystallized salt in 1000 
c.c. of water — 10 c.c. being added for every 100 mgrms. of the total 
amount of phosphoric acid found. After the addition of the barium 
the mixture is diluted to 100 c.c, filtered, and the phosphoric acid 
estimated in 50 c.c. of the nitrate. The result obtained is termed 
I). Owing to the fact that not only are the monophosphates pre- 
cipitated on the addition of the barium chloride, but also a small 
amount of normal phosphates, and that a small amount of diacid 
phosphate is formed at the same time and passes into solution, an 
error is incurred. This, however, remains constant, and amounts to 
3 per cent, in favor of the diacid phosphates. 

As the total amount of phosphoric acid is subject to fairly wide 
variations, even in health, it is best to calculate the relative propor- 
tion of T to D for 100 c.c. of urine, and then to determine the abso- 
lute degree of acidity for the twenty-four hours. Figures are thus 
obtained which are directly comparable with one another. 

1 E. Freund. Centralbl. f. d. med. Wiss, 1892, p. 689. 



CHEMISTRY OF THE URINE. 315 

Example. — Supposing that T amounted to 0.386 gramme for 100 
c.c. of urine, and D to 0.338 gramme. Three per cent, of D would 
have to be deducted for reasons just given, making the true value 
of D 0.3279. The relative proportion of T to D would then be 
84.9, as determined according to the equation 

0.3S6 : 0.3279 : : 100 : x ; and x = 84.9. 

Supposing, further, that the total amount of urine was 2000 c.c., 
the total acidity of the twenty-four hours would correspond to 1698, 
according to the equation 100 : 84.9 : : 2000 : x; and x = 1698, and 

the total acidity per hour to — - -, i. c, 70.7. 

The results obtained can also be expressed in terms of hydrochloric 
acid, 100 mgrms. of the diacid phosphates corresponding to 102.8 
mgrms. of hydrochloric acid. This mode of indicating the total 
acidity of the urine would actually be the better. 

If the urine should be alkaline and cloudy, the sediment is first 
dissolved by carefully adding a one-tenth or one-fourth normal solu- 
tion of hydrochloric acid, the amount added being then deducted 
from the total acidity. Should negative values be found, these could 
be expressed in terms of sodium hydrate. 1 

With this method a complete revision of all the work previously 
done will be necessary. The results given above have reference 
only to the old method of titration with a one-tenth normal solution 
of sodium hydrate. 

CHEMISTRY OF THE URINE. 

General Chemical Composition of the Urine. — A general idea 
of the chemical composition of the urine and the quantitative varia- 
tions of the individual components may be formed from the follow- 
ing table, which I have constructed from analyses made in my labor- 
atory. The individuals from which the urine- were obtained were 
adults, and their general mode of life, as regards diet, exercise, etc., 
was that of the average American city-dweller. In addition, the 
following substances may be encountered under pathological con- 
ditions : serum-albumin, serum-globulin, albumoses, mucin (oucleo- 
albumin), glucose, lactose, inosit, dextrin, biliary constituents, viz., 
bile-acids and bile-pigments, blood-pigments, melanin, leucin, tyro- 
sin, oxybutyria acid, allantoin, fat, lecithin, cholesterin, acetone, 
alcohol, Baumstark's substance, urocaninic acid, rystin, hydrogen 
sulphide, and still others. 

1 The urine is carefully guarded against ammoniacal decomposition by the addition, 

to the first portion voided, of from 20 to 25 C.C. of a solution of 10 grammes of oil of 
peppermint to 100 c.c. of alcohol ; or. a few cubic centimeters of chloroform are added, 
which answer the same purpose. 



316 THE URINE. 

Analysis of Ukeste. 

Water 1200-1700 grammes. 

Solids 60.0 

Inorganic solids 25.0 -26.0 

Sulphuric acid i H,S0 4 ) 2.0-2.5 

Phosphoric acid I P,0 5 "l 2.5-3.5 

Chlorine (NaCl) 10.0 -15.0 

Potassium (K>0) 3.3 " 

Calcium (CaO) 0.2-0.4 " 

Magnesium (MgO) 0.5 

Ammonia (NIL/l 0.7 u 

Fluorides, nitrates, etc 0.2 

Organic solids 20.0 -35.0 " 

^ Urea 20.0 -30.0 

Uric acid 0.2-1.0 

Xamhin bases 1.0 

Kreatinin 0.05- 0.08 " 

Oxalic acid 0.05 " 

Conjugate snlphates 0.12- 0.25 " 

Hippuric acid 0.65- 0.7 " 

Volatile fatty acid 0.05 " 

Other organic solids 2.5 

Quantitative Estimation of the Mineral Ash of the Urine. — 

In order to estimate the amount of mineral ash in the urine the 
following method may be employed : 

Fiftv e.c. of urine are evaporated to dryness in a weighed porce- 
lain dish, at a temperature of 100 c CL, and then heated, while 

Fig. 9 




Desiccator. (W. Simo>".) 

covered, over the free flame until gases cease to be evolved, care 
being taken not to heat too strongly in order to avoid sputtering. 
The residue is taken up with distilled boiling water, and, after 
standing, filtered through a Schleicher and Schull's filter, the weight 
of the ash of which is known. The dish and the contents of the 
filter are well washed with hot water. Filtrate and washings are 
set a.-ide and the dish and filter dried in the oven at 115° C. The 



CHEMISTRY OF THE URINE. 317 

filter is now placed in the dish and slowly incinerated. So soon as 
the ash has turned white the filtrate and washings are placed in the 
same dish, evaporated at 100° C, and then carefully heated over 
the tree flame. Upon cooling in the desiccator (Fig. 80) the dish 
with its contents is weighed, the difference between its present and 
previous weight indicating the quantity of ash contained in 50 c.c. 
of urine. 

Precautions : 1. Care should be taken to allow the dish to be- 
come faintly red only for a moment, as some of the chlorine is 
otherwise volatilized. Some phosphoric acid may also escape, and 
too strong a heat, moreover, may cause the transformation of sul- 
phates into sulphides, the organic material present acting as a 
reducing agent. 

2. If the organic ash is not completely incinerated, it is best to 
allow the dish to cool and then to moisten the ash with a few drops 
of dilute sulphuric acid, when the heating is continued. 

The Chlorides. 

The chlorides which are excreted iu the urine are derived from 
the food. As they are thus present in a much larger amount than 
all other inorganic salts combined, and in quantity more than suf- 
ficient to supply the needs of the body-economy, the relatively large 
amount of chlorides found in the urine under physiological condi- 
tions, as compared with the other inorganic constituents, is readily 
explained. 

Of the alkalies in the urine, sodium in combination with chlorine 
exists in greatest amount, and for clinical purposes it is most con- 
venient to calculate the total quantity of chlorides found in terms 
of sodium chloride ; a small proportion also occurs combined with 
potassium, ammonium, calcium, and magnesium. 

From 11 to 15 grammes of sodium chloride, representing the 
total quantity of chlorine, are normally eliminated in the twenty- 
four hours, the amount depending, of course, directly upon that 
contained in the food ingested. If the amount of nourishment is 
diminished, a decrease in the elimination of the chlorides is observed. 
If this is carried to the point of starvation, the chlorides disappear 
almost entirely from the urine, the traces remaining being derived 
from the body -fluids. The latter retain tenaciously a certain amount, 
which differs but slightly from that normally present. If at this 
stage food containing sodium chloride is again taken, a portion will 
be retained in the body until the original equilibrium is restored. A 
similar retention may be observed lor a few days following the 
ingestion of large quantities of water, which causes an increased 
elimination of chlorides. 

This tenacity on the part of the body in retaining sodium chloride 



318 THE URINE. 

is strikingly seen when the potassium salt is substituted for the 
sodium salt ; in this case the amount of the sodium in the serum 
of the blood will be found to vary very slightly. 

It has also been shown that the excretion of sodium chloride 
can be increased very materially by the ingestion of potassium 
salts, notably the neutral potassium phosphate (K 2 HP0 4 ). This is 
supposed to decompose the sodium chloride present in the serum, 
resulting in the formation of potassium chloride and neutral sodium 
phosphate, which are both eliminated as foreign material ; a point 
is finally reached, however, when the sodium chloride ceases to be 
excreted. 

This provision of the economy, in virtue of which an increase in 
the elimination of the salt is followed by its retention, and a pre- 
vious retention by an increased elimination, is supposed to be refer- 
able to the albuminous metabolism taking place in the body. It 
may be stated, as a general rule, that any increase in the amount of 
circulating albumin will be followed by an increased elimination of 
chlorides, these having been previously retained by the albuminous 
bodies in consequence of the great affinity which exists between 
them. At the same time the elimination of the chlorides is influ- 
enced by the quantity of urine excreted, increasing and decreasing 
with its volume. 

Pathologically the excretion of the chlorides may vary within 
wide limits, diminishing on the one hand to zero and increasing 
on the other to 50 grammes or more in the twenty-four hours. A 
marked diminution, which in some cases may go on to a total 
absence, was formerly thought to be pathognomonic of acute croup- 
ous pneumonia. 1 More modern investigations, however, have shown 
that such a condition occurs to a greater or less degree in most acute 
febrile diseases, such as scarlatina, roseola, variola, typhus and 
typhoid fevers, recurrens, and acute yellow atrophy. 

The explanation of this phenomenon must be sought for, first, in 
a diminished ingestion of chlorides ; secondly, in a retention of these 
in the blood, which probably is associated with an increase in the 
amount of the circulating albumin ; thirdly, in a diminished renal 
secretion of water ; fourthly, in a possible elimination of a portion 
of the chlorides through other channels, as in cases of severe diar- 
rhoea, the formation of serous exudates, etc. 2 Intermittent fever 
appears to be an exception to this rule ; usually it is true the 
chlorides are diminished, but not to the extent seen in the other 
diseases mentioned. They have, moreover, been found to increase 
during and sometimes immediately after a paroxysm, this increase 
being, of course, followed by a corresponding diminution. 

The chlorides are diminished in all acute and chronic renal dis- 

1 Eettenbacber, Wien. med. Zeit., 1850, p. 373. Heller, Heller's Archiv, 1844, vol. 
i. p. 23. 2 Salkowski u. Leube, Lebre vom Ham, 1882, p. 174. 



chemiste? of Tin: urine. 319 

eases associated with albuminuria, owing to some extent at least 

to a diminished secretion of water. 1 

In all eases of carcinoma of' the stomach, and in chronic hyper- 
secretion associated with dilatation, a decrease is also observed, which 
in certain cases of hypersecretion and hyperacidity, the result of gas- 
tric ulcer, may go on to a total absence. 2 

In anaemic conditions the chlorides are likewise diminished, as 
also in rickets. In melancholia and idiocy a striking decrease is 
observed; in dementia, chorea, and pseudohypertrophic paralysis 
this is less marked. A total absence has been noted in pemphigus 
foliaceus, and a considerable diminution in the beginning of impet- 
igo, as also in chronic lead poisoning. 

The chlorides are found in increased amount, on the other hand, 
in all conditions in which retention has previously occurred, chief 
among these being the acute febrile diseases and cases in which a re- 
sorption of exudates and transudates, associated with an increased 
diuresis, is taking place. A marked increase has also been noted in 
some cases of diabetes insipidus, in which 29 grammes have been 
eliminated in the twenty-four hours. 3 A similar increase may occur 
in prurigo, in which, in one instance, 29.6 grammes were passed in 
twenty-four hours. 4 In cases of general paresis, during the first 
stage, an increased elimination goes hand in hand with an in- 
creased ingestion of food. In epilepsy the polyuria following the 
attacks is associated with an increase in the chlorides. 

Of drugs, certain diuretics, and some of the potassium salts, as 
has been mentioned, produce an increase : the chlorine contained in 
chloroform, whether administered internally or as an anaesthetic, is 
in part excreted iu the form of a chloride. Salicylic acid, on the 
other hand, is said to cause a temporary diminution. 

It is of practical importance to note that in acute febrile diseases 
the diminution in the chlorides appears to vary with the intensity 
of the disease, a decrease to 0.05 gramme pro die justifying the con- 
clusion that the case under observation is of extreme gravity. It 
may at times also indicate the previous occurrence of severe diarrhoea 
or the formation of exudates of considerable extent. A continued 
increase, on the other hand, should lead to the conclusion that the 
patient's condition is improving. 

The elimination of the chlorides also furnishes a fair index to the 
digestive powers of the patient. This rule also holds good for most 
chronic diseases. All other causes which might lead to an increase 
or decrease being eliminated, an excretion of from 10 to 15 gramme- 
indicates a fair condition of the appetite and a normal digestive 
power, a decrease being associated with the reverse. 

1 Rihrnann. Zeit. f. klin. Med.. 1886, vol. i. p. 513. 

2 ("Uuzinski. Berlin, med. Woc-h.. 1887, vol. xxiv. p. 983. 

3 Oppenheim. Zeit. f. klin. Med., vol. vi. 

4 v. Bruelf. Wien. med. Woch., 1871, p. 552. 



320 THE URINE. 

An increased elimination of chlorides occurring in cases of oedema, 
and associated with the existence of serons exudates, is always of 
good prognostic omen, pointing to a resorption of the fluid. 

A ntinued elimination of more than 15 to 20 grammes, all other 
causes being excluded, may be considered as pathognomonic of dia- 
betes insipidus. 

Test for Chlorides in the Urine. — The recognition of the chlo- 
rides in the urine is based upon the fact that the addition of a solu- 
tion of silver nitrate causes their precipitation, the reaction taking 
place according to the equation 

.-- T :~O s - IbO = AgCl — KaSa,. 

The silver chloride thus formed is insoluble in nitric acid. 

The test is made in the following manner : after having removed 
any albumin that may be present, according to methods given else- 
where (see Albumin t. a few cubic centimeters of urine are acidified 
in a test-tube with about 10 drops of pure nitric acid, and treated 
with a few cubic centimeters of silver nitrate solution (1 : 20). 
The occurrence of a white precipitate indicates the presence of 
chlorides. An idea may be formed at the same time of the quantity 
present ; the occurrence of a heavy, caseous precipitate points to a 
large amount. 

Quantitative Estimation of the Chlorides by the Method of 
Salkowski-Yolhard. 1 — TThen a solution of silver nitrate acidified 
with nitric acid is treated with a solution of potassium sulphocyanide 
or ammonium sulphocyanide. in the presence of a ferric salt, the 
potassium sulphocyanide first causes the precipitation of white silver 
sulphocyanide, which, like silver chloride, is insoluble in nitric acid : 

. " - K8C5I = J^BCK - KS 

As soon as every trace of silver is precipitated, it combines with 
the ferric salt to form ferric sulphocyanide, which is of a blood-red 
: : 

■ :>~ — Fe, so 4 J; = f-_ @cs , - ;:: 

I: the p is be ium sulphocyanide solution is of known strength, it 
- k :o estimate accurately the amount of silver present in the 
solution, the ferric salt serving as an indicator of the end of the re- 
action between the silver and the potassium sulphocyanide. 

Application to the urine : to urine which has been acidified with 
nitric acid an -fa silver solution of known strength is added, 

and the silver not used in the precipitation of the chlorides then esti- 
mated as indicated above. The difference between the quantity thus 
found and the total amount used will be that consumed in the pre- 

Z - '".;■■ : physiol. Chem.. xol. i. p. 16. and toL ii. p. 397. 



CHEMISTRY OF THE URINE. 32] 

cipitation of the chlorides, from which, knowing the strength of the 
silver solution, its equivalent in terms of sodium chloride is readily 
determined. 

Reagents required : 

1. A solution of silver nitrate of such strength that each cubic 
centimeter shall correspond to 0.01 gramme of sodium chloride. 

2. A solution of potassium sulphocvanide of such strength that 
25 c.c. shall correspond to 10 c.c. of the silver nitrate solution. 

3. A solution of a ferric salt, such as ammonio-ferric alum, satu- 
rated at ordinary temperature. 

4. Nitric acid (specific gravity 1.2). 
Preparation of these solutions : 

1. As pointed out, the silver nitrate solution is made of such 
strength that each cubic centimeter shall correspond to 0.01 gramme 
of sodium chloride ; in other words, a standard solution is employed. 

The silver nitrate must be pure, aud it is best to use the crystal- 
lized salt, and not the sticks wrapped in paper, which always contain 
reduced silver. Iu order to test the purity of the salt, about 1 
gramme is dissolved iu distilled water, heated to the boiling-point, 
the silver precipitated by dilute hydrochloric acid and filtered off. 
When evaporated in a platinum crucible the filtrate should leave 
either no residue at all or only a very faint one ; otherwise it is 
necessary to recrystallize the salt until the desired degree of purity 
is reached. 

The determination of the quantity to be dissolved in 1000 c.c. of 
water is based upon the fact that 1 molecule of silver nitrate 
(molecular weight 170) combines with 1 molecule of sodium 
chloride (molecular weight 58.5) to form silver chloride and sodium 
nitrate. As the solution of silver nitrate shall be of such strength 
that 1 c.c. corresponds to 0.01 gramme of sodium chloride, or 1000 
c.c. to 10 grammes, the quantity to be dissolved in 1000 c.c. is found 
according to the following equation : 

58.5 : 170 : : 10 : x, 58.5 x = 1700, x = 29.059. 

Theoretically, then, this quantity should be dissolved in 1000 c.c. 
of water. It is better, however, to dissolve it in a quantity some- 
what less than 1000 c.c, such as 900 or 950 c.c, as the silver salt 
contains water of crystallization and the weighed-off quantity would 
Dot represent the exact amount required, but less, the correcting of 
a solution which is too strong being a much simpler matter than 
that of a solution which is too weak. 

To make this correction, or, in other words, to bring the solution 
to its proper strength, 0.15 gramme of sodium chloride which has 
previously been dried carefully by heating in a platinum crucible, is 
accurately weighed off, dissolved in a little distilled water, and further 
diluted to about 100 c.c. To this solution a few drops of a solution 

21 



322 THE UBISE. 

of potassium chroniate are added, when the mixture is titrated witn 
the silver solution. 

The silver nitrate will first precipitate the sodium chloride, and 
then combine with the potassium chromate, forming red silver 
chromate, according to the equation 

2AgSO s - K 2 Cr0 4 = Ag 2 Cr0 4 — ZKSOs. 

The slightest orange tinge remaining after stirring indicates the 
end of the reaction. ^Vere the solution of the silver nitrate of the 
proper strength, exactly 1 5 c.c. should have been used, as each cubic 
centimeter shall represent 0.01 gramme of sodium chloride. As a 
matter of fact, less will in all probability be needed, the solution 
having been purposely made too strong. Its correction then be- 
comes a simple matter, as it is merely necessary to determine the 
degree of dilution required. 

Supposing that 29.059 grammes of silver nitrate were dissolved 
in 900 c.c. of water, and that 14.5 c.c. instead of 15 c.c. had 
been required to precipitate the 0.15 gramme of sodium chloride, 
it is evident that each 14.5 c.c. of the remaining solution must 
be diluted with 0.5 c.c. of water. It is, hence, only necessary to 
divide the number of cubic centimeters of the silver nitrate solution 
remaining by 14.5 ; the result multiplied by 0.5 represents the 
amount of water which must be added in order to bring the solution 
to the required strength. Hence the rule for the correction of a 
solution which has been found too strong : 

= ^4 

n 

in which C represents the number of cubic centimeters of water 
which must be added to the solution remaining ; JV the total number 
of cubic centimeters remaining after titration : n the number of 
cubic centimeters consumed in one titration ; and d the difference 
between the number of cubic centimeters theoretically required and 
that actually used in one titration. 

In the example given the equation would then read : 

14.5 

32.29 c.c. of distilled water are added to the remaining 

when the strength of the solution is tested by a second titration. If 
the solution is found too weak, it is best to make it too strong, and 
then to correct as described. 

2. Preparation of the potassium sulphocvanide solution : from 
the equation AgUO KSC X = AgSCX - K>" : is seen that 

1 molecule of silver nitrate (molecular weight 170) combines with 
1 molecule of potassium sulphocvanide (molecular weight 97). The 



CHEMISTRY OF THE URINE. 323 

quantity of the latter to be dissolved in 1000 c.c. of water is then 
found from the following equation : 

170 : 97 : : 11.6236 : a: ; 170 x = 11.6236 X 97 ; x= 6.6. 

As potassium sulphocyanide is extremely hygroscopic, a solution 
is made which is too strong-, by dissolving about 10 grammes of the 
salt in 900 c.c. of distilled water. In order to bring this solution to 
its proper strength, 10 c.c. of the silver solution are diluted to 100 
c.c.; 4 e.e. of nitric acid (specific gravity 1.2) and 5 c.c. of the am- 
monio-fenic alum solution are added, when the mixture is titrated 
with the potassium sulphocyanide solution ; the end-reaction is 
recognized by the production of a slightly reddish color, which per- 
sists on stirring. The sulphocyanide solution having been purposely 
made too strong, it will be found that less than 25 c.c. are needed to 
precipitate all the silver present. The quantity of water necessary 
for dilution is ascertained, as above, according to the formula 

n 

3. The solution of ammonio-ferric alum is a solution saturated at 
ordinary temperatures, care being taken to insure the absence of 
chlorides in the salt, which may be effected, if necessary, by recrys- 
tallization. 

Method as Applied to the Urine. — Ten c.c. of urine are placed in a 
small stoppered flask bearing a 100 c.c. mark, diluted with 50 c.c. 
of distilled water, and acidified with 4 c.c. of nitric acid. From a 
burette 15 c.c. of the standard solution of silver nitrate are added. 
The mixture is thoroughly agitated and diluted with distilled water 
to the 100 c.c. mark. The silver chloride formed is filtered off 
through a dry folded filter into a dry graduate; 80 c.c. of the 
filtrate are placed in a beaker, and, after the addition of 5 c.c. of the 
ammonio-ferric alum solution, titrated with the sulphocyanide solu- 
tion until the end-reaction — i. e., a slightly reddish tinge — is seen. 
If necessary, two such titrations should be made, the sulphocyanide 
solution being added 1 c.c. at a time in the first, while in the second 
the total number of cubic centimeters needed to bring about the 
end-reaction, less 1 c.c, arc added at once, and then 0.1 c.c. at a 
time. 

The amount of chlorides present in the urine is calculated as fol- 
lows : 

Example. — Total quantity of urine 600 c.c. ; 6.5 c.c. of the 
sulphocyanide solution were required to bring about the end-reaction 
in 80 c.c. of the filtrate; this would correspond to 8.125 c.c. for 
the total 100 c.c. of filtrate, representing 10 c.c. of urine, as is seen 
from the equation 

n:80::x:100; 80z = 100n; x = ] — =— , 

80 4 



--- zzi :.£3ie 

— ~— -- - -Tiiirsiii- m ::n;e: ;: nil; -in,i:> 
\ ----- : - ' - - "-- il-iTc ..ii lie ini r: : : 

These 8.125 e.e. were used in precipitating the silver nitrate not 
Bompoeed by the chloritl- As ." >£ the solphocyanide 

mi : -:-;,■- i- : . . : . "_; ; . : i_ T r_v c i - m; z — I n: T ~ :: 
'-- --: — - - — :-i- jrnm-rid- := : ;i. mil :'_,- - i i n 

35:1®:::" i ii=] ff g = J*J = l— 

— ~— -— - ripnseii- iir -hit — : ill -iVei - " - i ii ill:: 
viiirx:: in _' :._ i : ii- -i..- '__-. ■- ■-_.-_ ] - 7 i: i ;. - : i; 
- -'- --H : ii- - ii i : ~i- ii iii- .•: — -n^ _ T : : 

--- hitHi er^r-n t_t r : nl :. n ::: ;: »i i: - Ini i fn- 



: : : t:ii- n ii T • — ii .-. : :>:.-.: - :: i 
gloved. As 1 e.e. of the diver solution repre- 

" - - :m i_: n - 11111 _i>: __: ~t ■ -n i- :: 
rii- Ml": i-r nif :i 1 \ ' : : It: - 



From these considerations die following short rale results : instead 
of first multiplying the member of cubic centimeters of the potas- 

:™ - "i~i '■:"":.:".: f sin i inisi- i 'i v : - : ; : :"_- in-. 
by -f-, and the result by -|, in order 1 ii 111 i m : 



of die potassium sulphocyanide solution representing' 

excess of silver nitrate in 100 e.e. of the filtrate, and then 
deducting the result from 15. it is simpler to multiply by J directly 

'"-'■- - iili ii-- ii I". :!- imiTi : _. -in.— : - "in 

1 rlii :v:ii:ii-l n "_ : : : liii '-:::_ i - : i _"..:« 

figure is then corrected for the total amount of urine. 

7_ :iiii -1 -- :: -•. 1117 :- mil -7^1 1: :i- ':-- -.1 - : :. > 

- J. ■ . 11 f 111 _" — T~rl 11 1ST -. 1T1S1 S: 

as to insure die absence of nitrous acid. 

Z ::: M flood — - : 1 accuracy is not required, the fbl- 

: - - --_ - . - - . .. - 

Ten ce. of urine are dfluted with distilled water to 100 e.e. and 

-.---.-" —.11 :- - 1 -- : - - ~ - 1 : i.-iis-iin lii'iiii- 111- 
mixture is titrated with a oae-temth normal solution of silver nitiate 
until the end-reaction is reached — L «l, a faint orange tinge — which 
no longer disappears on stirring. The number of cubic eemti- 

■.---> - • . . iii -.■.-■ 7 1 1.1: iiiii mi: 1 ;_. 1: fs 

1 ;---i i" :i 1 i "■: 111- 

- - . . . - , - . ; -- _ " .. 

7 :: : 1 .-_: . _ ■ 7 .-;•.-_■■■ .-- 



CHEMISTRY OF THE URINE, 325 

and pigments are also precipitated by the silver nitrate, the end- 
reaction is delayed ; moreover, unless the urine is very pale, its 
recognition may be difficult, and the error thus caused considerable. 
This is especially true of febrile urines which contain only a small 
amount of chlorides. 

Should iodides or bromides have been taken, these must first be 
removed, as silver iodide and bromide, which are insoluble in nitric 
acid, would give too high a value. 

To this end, the following method, which is also a very accurate 
one, should be employed, its only disadvantage being the amount of 
time required. 

Estimation of the Chlorides after Incineration (according to 
Neubauer and Salkowski). 1 — The principle of this method is the 
destruction of all organic material and the subsequent estimation of 
the chlorides contained in the mineral ash by one of the methods 
described. Ten c.c. of urine are evaporated to dryness in a platinum 
crucible at a temperature slightly below 100° C, after the addition 
of a little pure dried sodium carbonate and from 3 to 5 grammes 
of potassium nitrate. The addition of the sodium carbonate insures 
the conversion of any ammonium chloride which may be present 
into sodium chloride ; the potassium nitrate acts merely as an oxi- 
dizing agent. The residue is now carefully heated at a moderate tem- 
perature, allowed to cool, dissolved in distilled water, and accurately 
neutralized with very dilute nitric acid. In this solution the chlorides 
are estimated most conveniently according to the second method. 

Should iodides or bromides be present, the aqueous solution just 
referred to is acidified with sulphuric acid, and the iodine and 
bromine thereby liberated extracted with carbon disulphide. As 
complete removal of these bodies is, however, only possible in the 
presence of a nitrite, it is better not to rely upon the presence of 
any that may have been formed during the process of incineration, 
but to add a few drops of a solution of potassium nitrite. After 
extraction the nitrous acid is decomposed by the addition of a little 
urea. The solution is then neutralized with sodium carbonate; 
should it be alkaline, dilute acetic acid is added until neutral. In 
this solution the chloride- are most conveniently estimated according 
to the second method. 

Albumin and sugar, if present, should be removed before the 
addition of the sodium carbonate and potassium nitrate, so as to 
obviate losses from sputtering, which otherwise would occur. Nitrous 
acid must also be removed for reasons given above. 

The Phosphates. 

The phosphates occurring in the urine are sodium, potassium, cal- 
cium, and magnesium salts of the tribasic acid H 3 P0 4 . The most 

1 K. Salkowski. Pfliiger's Arcliiv, vol. vi. p. 214. 



326 THE URISE. 

important of these, as was pointed out in the chapter on Reaction, 
is the diaeid sodium phosphate NaHJPO^ to which the acidity of 
the urine is due. It is owing to the presence of this salt in the 
urine that the calcium phosphate is held in solution ; the fact, at 
least, that calcium and magnesium phosphates are thrown down 
when the urine is neutralized, would point to this conclusion. 

The composition of the phosphates is liable to considerable varia- 
tion, depending upon the degree of acidity of the urine. As would 
be expected, diaeid sodium phosphate and diaeid calcium phosphate 
are present in an acid urine ; in an amphoteric urine, in addition to 
these there are found disodinm phosphate, monocalcium phosphate, 
and niononiagnesiuni phosphate, while in an alkaline urine trisodic 
phosphate, neutral calcium phosphate, and neutral magnesium phos- 
phate may be present. 

The alkaline phosphates normally exceed the earthy phosphates 
by one-third, and sodium is combined with far the greater amount 
of phosphoric acid, the potassium salt normally occurring in only 
very small amounts. 

In addition to the mineral phosphates, phosphoric acid is excreted 
also in combination with glycerin as glycerin-phosphoric acid, which 
need not. however, be considered in a quantitative estimation, as it 
is present only in traces. 1 

As in the case of the chlorides, the greater portion of the phos- 
phates is derived from the food, while only a small portion is refer- 
able to the phosphorus built up in the proteid molecule, be this in 
the form of a muscle-cell, a nerve-cell, a red blood-corpuscle, or bone. 
But just as the percentage of sulphur varies in the different tissues, 
also does that of phosphorus vary ; nerve-tissue, for example, 
which is very rich in lecithin and nucleins, yields relatively more 
phosphorus than muscle-tissue. 

Not all the phosphoric acid ingested, however, is excreted in the 
urine, as one-third to one-fourth of the total quantity is eliminated 
in the feces. 

The quantity of phosphoric acid excreted, which normally varies 
between 2.5 and 3 grammes, is thus largely dependent upon the 
amount ingested, increasing with an animal and decreasing with a 
vegetable diet. 2 During starvation a considerable increase is like- 
wjge observed, referable, no doubt, to an increased destruction of bony 
tissue, which is very rich in the phosphates of the alkaline earth-. 
In accordance with this view, increased amounts of calcium and 
magnesium are also seen during starvation. The relation between 
the excretion of phosphoric acid and nitrogen, normally 1 : 7, changes, 
moreover, in such a manner that both the absolute and the relative 
amount of phosphoric acid, as compared with the uitrogen, increases ; 

1 Lepine et Eymonnet. C<>mpt. rend, de la Soc. de BioL, 18821 

- Zulzer. Virchow's Archiv. vol. lsvi. p. >23. 



CHEMISTRY OF THE URINE. 327 

this leads to the conclusion that in addition to the muscles some 
other tissue rich in phosphorus and relatively poor in N must suffer 

during the process, and the only one which could enter into con- 
sideration is bone. 1 If at this time food containing phosphorus is 

again given, a retention will take place, SO that the general rule 
stated in the chapter on Chlorides, that increased elimination is fol- 
lowed by a certain degree of retention, and that a previous retention 
i< t'ol lowed by an increased elimination, seems to hold good for all 
the mineral acids found in the urine (sec also the chapter on 
Sulphates). 

An increased elimination is caused also by the ingestion of large 
quantities of water, which is followed by a certain degree of reten- 
tion. 

Observations on the phosphatic excretion during muscular exercise 
have not given uniform results. 2 Mental exercise appears to cause a 
diminished excretion of the alkaline phosphates and an increased 
elimination of the earthy phosphates. 3 The latter also takes place 
during sleep. 

In disease the total amount of phosphates may either be increased 
or diminished. 

A diminished elimination is observed in most cases of acute febrile 
disease, such as pneumonia, typhoid fever, typhus fever, recurrens, 
during a paroxysm of intermittent fever, etc. The degree of dimi- 
nution is usually proportionate to the severity of the disease, reaching 
its lowest figure as death approaches. Such a state of affairs may, 
at first sight, appear paradoxical in view of what has been said above 
of the etfects of tissue-destruction upon the elimination of phos- 
phates. It is necessary, however, to distinguish sharply between an 
increased production and an increased elimination ; in all probability 
a retention occurs analogous to that of the chlorides, which may be 
observed under the same conditions. It has been supposed that the 
phosphates set free during the process of tissue-destruction are 
utilized in the building up of new leucocytes, and an increase in 
these is actually noted in some of the diseases mentioned. A dimin- 
ished excretion of phosphates is, however, not always observed, 
and an increased elimination may occur in certain cases. In fatal 
cases this condition may persist even until the time of death. It 
is very difficult to give a satisfactory explanation of this fact at 
the present time. The phenomenon, in typhoid fever at least, 
appears to be connected with the intensity of the nervous manifesta- 
tions, and Robin concludes that here an increased elimination during 
the fastigium is an unfavorable omen, while an increase during defer- 
vescence warrants a favorable prognosis. A similar decrease in the 

i Ziilzer. loc. (it. 

2 Fleischer u. Penzoldt, Virchow's Archiv, vol. lxxxvii. p. 210. 

3 Mairet, Compt. rend, de la Soc. de Biol., 1884. 



32% THE UBLSE. 

phosphates lias also been observed in pulmonary phthisis associated 
Trith high level 

interesting and important is the diminished excretion of 
the phosphates associated with acute and. to some extent also, with 
chronic nephritis, amyloid degeneration of the kidneys, and the 
anaemias, in which an actual insufficiency on the part of the kidneys 
in the eli min ation of these salts appears to exist.- 

A diminished or. at least, no increased excretion is seen in certain 
diseases : die bones, such as osteomalacia, although au increase in 
the earthy phosphates has been noted. This may depend either upon 
a retention or an elimination through other channels. The earthy 
_ sphates especially are found in greatly diminished amount, or 
may even be absent altogether in certain cases of nephritis. A 
similar condition is observed in acute and chronic rheumatism. 

The data regarding the phosphatic elimination in nervous and 
mental diseases ire, :n the whole, scanty and by no means uniform. 

During attacks of hysteria major, in contradistinction to epilepsy. 
in which an increased elimination takes place, the phosphates are 
diminished, the decree oi' diminution being generally proportionate 
to the intensity of the attack, increasing again together with the other 
nrinai ~ nstituenis with the s abseqnent increase in the dinrc sis. 2 

In chronic lead poisoning a diminution to one-third of the normal 
quantity may occur. Very low figures have been noted in Addis n's 
disease, in acute yellow atrophy (in which even a total absence may 
occur), and in certain cases of hepatic cirri: 

An increased elimination of phosphates, on the other hand, amount- 
ing in some easr- : " or even to 9 grammes in the twenty-four 
hour- has been -::ibed by Teissier. :: Lyon, under the name of 
phosphatic diabetes, the patient presenting various symptoms com- 
monly seen in diabetes mellitus : sugar, however, is usually absent. 
Whether not phosphatic diabetes is a disease svi generis is not 

certain. 4 

In true diabetes mellitus a curious relation has been found to 
the elimination of sugar and of phosphates, the quan- 
tity of the latter rising and falling in an inverse ratio to the amount 
: sugar. In diabetes insipidus a slight increase is at times found. 

Corresponding to the phosphatic retention observed in acute febrile 
lis ses an increased elimination is noted during convalescence. An 
increase occurs in the course ce :- brospinal meningitis. 

In a case of pseudoleukemia an incre: sc : grammes ha- 
noted, while the number of red corpuscles fell from l.l . . . : 
800,000 in four days. To judge from the very careful observations 

i ---.-■-.,- Sdunktl s Jalures bcvLj r 9. 

- ' -- -- l f. klin. M- " - ~ mx.p-129. 

- - •-. 7 -------- -~ " - -/- 7 " ""-: : ■". :-:---" '■ ^ :-- "_ ~- ■■- 1 f~- 

- B Phosphatie Diabetes." Lancet. March 24. 1900L Teissier. These, 

53 



CHEMISTRY OF THE URINE. 329 

made, there could be do doubt that the high degree of phosphaturia, 
which was Limited to the alkaline phosphates, was referable to this 
latter source. In leukaemia also an increase to 7 grammes has been 
observed on the day preceding death ; commonly, however, the in- 
crease is but slight in this disease. 1 

While it is apparent that important conclusions cannot be drawn, 
on the whole, from a knowledge of the absolute phosphatic elimina- 
tion, unless it be from a study of the relation existing between the 
excretion of the alkaline and earthy phosphates, a study of the rela- 
tive phosphaMc excretion seems to promise more valuable results. 
According to Ziilzer, 2 a definite amount of the phosphates and of the 
urinary nitrogen is referable to the destruction of albuminous mate- 
rial, so that the relation between the phosphoric acid and the nitro- 
gen must be constant. Another portion, however, is derived from 
lecithin, one of the most important constituents of nerve-tissue, 
which contains more phosphorus than the albuminous molecule. 
Whenever, then, the lecithin-containing tissues are more involved 
in the general metabolism than under normal conditions the rela- 
tion will no longer be a stable one. This relation which exists 
between the elimination of nitrogen and phosphoric acid has been 
termed the relative value of phosphoric acid. 

The relative value of phosphoric acid in the urine has been calcu- 
lated as varying from 17 to 20, that of the blood being 3, of muscle- 
tissue 12.1, of brain 44, of bone 426 to 430. This value supposes 
the absolute value to vary between 2 and 3 grammes pro die. It is 
found according to the following equation : 

X : P 2 5 : : 100 : x ; and x = 1°^— ?A, 

N 

in which X indicates the amount of nitrogen actually observed, 
P 2 5 the amount of phosphoric acid in the same specimen of urine, 
and x the amount of P 2 0. corresponding to 100 grammes of N. 
By observing this relative value a much better idea may be formed 
of the metabolic processes taking place in the body in disease than 
from a mere expression of the absolute phosphatic value. 

In acute febrile diseases the relative as well as the absolute dimi- 
nution of the phosphates has been ascribed to a retention, they being 
possibly utilized in the building up of white blood-corpuscles. In 
the course of these diseases oscillations in the relative value are fre- 
quently observed ; during convalescence the relative as well as the 
absolute value again rises. 

In accordance with these considerations a diminished relative ex- 
cretion of phosphoric acid should be expected in all cases associated 
with a notable elimination of leucocytes through other channels, as 
iu pneumonia, for example, or a storing away of the same, as in 

1 Fleischer u. PenzoMt, loc. cit. 2 Loc. cit. 



330 THE UBINK 

cases of empyema. The facts observed are in accord with this 
view. 

A relative decrease has further been noted in the various forms of 
anaemia, conditions of cerebral excitation, and especially preceding 
an attack of epilepsy. In progressive paralysis following syphilis 
the relative value, at first low, rises greatly after the administration 
of potassium iodide, while the excretion of the earthy phosphates is 
lessened. In chronic cerebral affections, delirium tremens, and acute 
hydrocephalus a relative decrease has been noted. In mania, during 
the period of excitement, both the alkaline and the earthy phosphates 
are found increased, while during the stage of depression, as also in 
melancholia, the alkaline phosphates are diminished and the earthy 
phosphates increased. On the other hand, an increase in the relative 
value has been noted in apoplexy (amounting to 34.3 in one case, 
two days after an attack), brain tumors, tabes, arthritis deformans 
(30), pernicious anaemia (23.8—58), etc. 1 

Of drugs, bromides appear to diminish the absolute amount of 
phosphoric acid. Cocain and quinin cause a decrease, and salicylic 
acid an increase. A relative decrease is produced by the cerebral 
excitants, such as strychnin, small doses of alcohol, phosphorus, 
valerian, cold baths, salt-water baths, etc. An opposite effect is 
produced by the cerebral depressants, such as chloroform, morphin, 
chloral, large doses of alcohol, potassium bromide, mineral and 
vegetable acids, prolonged cold baths, Turkish baths, low tempera- 
ture, etc. 

Tests for the Phosphates in the Urine. — The test for the detec- 
tion of the phosphates occurring in the mine depends upon the pre- 
cipitation of phosphoric acid by means of ferric chloride as ferric 
phosphate, which is insoluble in cold acetic acid : 

2NaH 2 PO i -f Fe 2 CI 6 =Fe 2 (P0 4 ) 2 — 2XaCl + 4HC1, 
2Xa 2 HP0 4 - FeXl 6 = Fe 2 (POJ 2 - 4NaCl - 2HC1. 

The same result may be accomplished by the addition of a solution 
of uranyl nitrate ; this gives rise to the formation of uranyl phos- 
phate, which is also insoluble in acetic acid : 

Na 2 HP0 4 + 2UO.N0 3 = 2NaNO a - (TT> 2 HPO„ 

0F Na 2 HP0 4 -4- UO.X0 3 =NaNO + PO.H 2 P0 4 . 

Test. — A few cubic centimeters of urine are acidified with a few 
drops of acetic acid, and treated with a few drops of a solution of 
ferric chloride (1 part of the officinal solution to 10 parts of water), 
when the occurrence of a yellowish- white precipitate will indicate 
the presence of phosphates. 

1 Ziilzer a. Edlefsen. loc. cit. 



CHEMISTRY OF THE URINE. 331 

Ifa solution containing- an acid phosphate of the alkalies is treated 
with an alkaline hydrate, the diaeid alkaline phosphate is trans- 
formed into the monaeid salt, according to the equation 

NaII,P() 4 + NH 4 OH = NaNII 4 HP<) 4 | H 2 0. 

This is further changed into the normal salt, as represented : 
3XaXII 4 HP0 4 + NH 4 OH = Na 3 P0 4 + (NH 4 ) 8 (P0 4 ) 2 + 11,0. 

As the monaeid and neutral salts are both readily soluble, the 
solution remains clear. If at the same time, as in the urine, a 
soluble diaeid phosphate of the alkaline earths is present, this like- 
wise is transformed into the monaeid and fiually into the neutral 
salt ; the latter, however, being insoluble, is thrown down : 

(1) Ca(H,P0 4 ) 2 + 4XH 4 OH = Ca(XH 4 ) 2 (P0 4 ) 2 + 4H 2 0. 

(2) 3Ca(NH 4 ) 2 (P0 4 ) 2 = O^PO,), + 2(NH 4 ) 3 P0 4 . 

Test for the Earthy Phosphates. — Ten c.c. of urine are 
rendered alkaline with ammonia, when the occurrence of a flocculent 
precipitate will indicate their presence. 

Test for the Alkaline Phosphates. — After having removed 
the earthy phosphates from 10 c.c. of urine, as just described, the 
clear filtrate is acidified with acetic acid and tested with ferric chlo- 
ride or uranyl nitrate, as shown above. 

The alkaline phosphates may also be detected by treating the 
ammoniacal filtrate with a few drops of magnesia mixture (1 part of 
crystallized magnesium sulphate, 2 parts of ammonium chloride, 4 
parts of ammonium hydrate, and 8 parts of distilled water), when 
ammonio-magnesium phosphate, which is almost insoluble in ammo- 
nium hydrate, will be thrown down. The reaction takes place be- 
tween the monaeid or neutral sodium phosphate and the magnesium 
sulphate according to the equation 

NajHPCVf- MgS0 4 + XH 4 OH + NH 4 C1 = MgNH 4 P0 4 4- NH 4 C1 + Xa,SO, -\ IK >. 

Quantitative Estimation of the Total Amount of Phosphates. 
— Principle. — When a solution of disodium phosphate acidified with 
acetic acid is treated with a solution of uranyl nitrate or uranyl 
acetate, a dirty-looking, white precipitate of uranyl phosphate is 
thrown down, which is formed according to the equation given 
above. It is apparent that the quantity of phosphoric acid can be 
estimated accurate]}', if the solution of uranyl nitrate or acetate is of 
known Btreneth. 

Solutions required : 

1. A solution of uranium nitrate of such strength that 20 c.c. 
shall correspond to 0.1 gramme of P 2 5 . 



332 THE URINE. 

2. A solution containing sodium acetate and acetic acid. 

3. Tincture of cochineal. 
Preparation of these solutions : 
1. From the equation 

2UO.NO, + NagHP0 4 = (UO) 2 HP0 4 - 2NaN0 3 

it is apparent that 2 molecules of uranium nitrate combine with 1 
molecule of disodium phosphate to form uranium phosphate and 
sodium nitrate. The molecular weight of uranium nitrate being 
318 aud that of disodium phosphate 142, it is seen that 636 parts 
by weight of the former combine with 142 parts by weight of the 
latter. 

As 20 c.c. of the solution of uranium nitrate shall correspond to 
0.1 gramme of P 2 5 , 1000 c.c. must be equivalent to 5 grammes of 
P 2 5 . In 142 parts by weight of disodium phosphate there would 
be present 71 grammes of P 2 5 , equivalent to 636 parts by weight 
of uranium nitrate. The quantity of the latter, then, to be dis- 
solved in 1000 c.c. of water will be foimd from the equation : 636 : 
71 : : x : 5 ; and x = 44.78. 

44.78 grammes of uranium nitrate are weighed off and dissolved 
in about 900 c.c. of water, the solution being purposely made too 
strong for reasons pointed out in the chapter on Chlorides. In 
order to bring this solution to its proper strength it is necessary to 
titrate with the uranium solution a solution of disodium phosphate 
of such strength that each 50 c.c. shall contain 0.1 gramme of P 2 0., 
or 1000 c.c. 2 grammes. The molecular weight of Xa 2 HP0 4 + 
12H.X> being 358, this amount of disodium phosphate in grammes 
is equivalent to 142 grammes of P 2 0- ; the quantity of P 2 5 cor- 
responding to 2 grammes, in terms of Xa 2 HP0 4 — 12H 2 0, is found 
from the equation : 358 : 142 : : x : 2 ; and x = 5.042. Tins 
amount of pure, dry. and non-deliquescent Xa 2 HP0 4 is dissolved in 
1000 c.c. of distilled water. If non-deliquescent disodium phos- 
phate is not at hand, about 6 or 7 grammes of the salt are dissolved 
in 1000 c.c. of distilled water ; of this solution 50 c.c. are evapo- 
rated in a weighed platinum dish, and the residue gently heated, the 
disodium phosphate being thereby transformed into sodium pyro- 
phosphate, Xa 4 P 2 7 , according to the equation 

2Xa 2 HP0 4 = Na 4 P a O, - H 2 0. 

The molecular weight of Na 4 P 2 7 being 266, this corresponds to 
142 grammes of P 2 0-. If the solution is of the correct strength 
— i. e., containing 0.1 gramme of P 2 0- in 50 c.c. of water — the 
residue should weigh 0.1873 gramme, as is seen from the equation : 
132 : 266 : : 0.1 : x; and x = 0.1873. Supposing, however, that the 
residue weighs 0.1921 gramme, it is manifest that the solution is 



CHEMISTRY OF THE URINE. 333 

too strong, and must be diluted, the degree of dilution being ascer- 
tained according to the equation : 0.1873 : 1000 : : 0.1921 : x; and 
X = 102") ; i. c, 1000 c.c. of the solution must be diluted to 1025 
e.c. to make it of the proper strength. 

In the ease given, 50 e.e. were used ; the 950 c.c. are then diluted 
with the amount of water found from the equation : 1000 : 1025 : : 
950 : x ; and x = 973.75. Having thus obtained a solution of diso- 
dium phosphate of such strength that each 50 c.c. shall contain 0.1 
gramme of P 2 5 , this is titrated with the uranium solution, which 
has been made too strong, in order to determine the amount of 
water that must be added to the latter. To this end, a burette is 
tilled with the uranium solution; 50 c.c. of the disodium phosphate 
solution are treated with a few drops of the tincture of cochineal 
and 5 c.c. of the acetic acid mixture (see below). This mixture is 
heated in a beaker, and as soon as the boiling-point has been reached 
titrated with the uranium solution until a trace of a greenish color 
is noticed in the precipitate which does not disappear on stirring. 
This point having been accurately determined by means of a second 
titration, the number of cubic centimeters of distilled water with 
which the remaining solution must be diluted is determined accord- 

K (1 
iug to the formula : C = ^ ' , in which C represents the number 

of cubic centimeters which must be added, iVthe number of cubic 
centimeters remaining after the test-titration, n the number of cubic 
centimeters consumed in one titration to bring about the end- 
reaction, and d the difference between the number of cubic centi- 
meters used in one titration and that theoretically required. The 
amount of distilled water necessary for dilution is now added and 
the solution again testad, when 20 c.c. will correspond to 0.1 gramme 

of p 2 o,- 

2. The acetic acid mixture consists of about 100 grammes of 
sodium acetate dissolved in distilled water, and 100 c.c. of a 30 per 
cent, solution of acetic acid, the whole being diluted to 1000 c.c. 

3. Tincture of cochineal. This may be prepared as follows : a 
few grammes of cochineal granules are digested at ordinary tempera- 
tures with 250 c.c. of a mixture of 3 volumes of water and 1 volume 
of 94 per cent, alcohol. The solution is then decanted and ready 
for use. The residue may be utilized in the preparation of a fresh 
supply of the tincture. 

Application to the Urine. — Fifty c.c. of clear filtered urine arc 
treated with 5 c.c. of the acetic acid mixture, the object being to 
transform any monacid sodium phosphate present into diacid sodium 
phosphate, and to neutralize any nitric acid that may be formed 
during the titration, as otherwise the nitric acid would cause a partial 
solution of the precipitated uranyl phosphate. A few drops of the 
tincture of cochineal are added, when the mixture is heated to the 



334 THE URINE. 

boiling-point and titrated as described above ; two titrations are 
usually required. 

The results are then calculated as follows : supposing 15 c.c. of 
the uranium solution to have been used, the corresponding amount of 
P 2 5 in 50 c.c. of urine is found from the equation : 20 : 0.1 : : 1 5 : x ; 
and x = 0.075. The percentage-amount would, hence, be 0.075 X 
2 = 0.15. Supposing the total amount of urine to have been 2000 
c.c, the elimination of P 2 5 would correspond to 3 grammes. 

The presence of sugar and albumin does not interfere with the 
method. 

Separate Estimation of the Earthy and Alkaline Phosphates. 
— If the alkaline and earthy phosphates are to be determined sepa- 
rately, the total amount of P 2 5 is estimated in one portion of the 
urine, while the P 2 5 in combination with the alkaline earths is 
determined in another, as follows : 

Two hundred c.c. of filtered urine are made strongly alkaline with 
ammonium hydrate and set aside, covered, for several hours, when 
the earthy phosphates thus precipitated are collected on a filter, 
washed with dilute ammonia (1 : 3), and then transferred to a beaker, 
with the aid of a little water containing a few drops of acetic acid, 
by perforating the filter. They are then dissolved with as little 
acetic acid as possible, diluted to 50 c.c. with distilled water, and 
titrated with the uranium solution as described. The difference 
between the total amount of P 2 5 and the amount thus obtained 
indicates the quantity of alkaline phosphates present. 

Removal of the Phosphates from the Urine. — Whenever it is 
necessary to remove the phosphates from the urine in the course of 
an analysis, as is frequently the case, the urine is rendered alkaline 
by the addition of the hydrate of an alkaline earth and precipitated 
with a soluble calcium or barium salt. They may also be precipi- 
tated by means of neutral or basic lead acetate, in wliich case the 
excess of lead is removed by means of hydrogen sulphide or dilute 
sulphuric acid. 

The Sulphates. 

The sulphuric acid found in the urine is derived essentially from 
the albuminous material which is constantly broken down in the 
body, a very small portion only of the inorganic sulphates being 
referable to the mineral constituents of the food. As was pointed 
out in the chapter on Reaction, sulphuric acid is constantly produced 
in the body, and, coming into contact with the so-called neutral 
phosphates present in almost all the tissues, transforms these into 
acid phosphates, according to the equation 

2Na 2 HP0 4 + H 2 S0 4 = 2NaH 2 P0 4 + Na 2 S0 4 , 

both appearing in the urine. The alkaline carbonates, which are 



CHEMISTRY OF THE URINE. 335 

derived from the organic salts ingested by a process of oxidation, 
are also attacked by the sulphuric acid. 

As the amount of food ingested is gradually diminished a point is 

reached when the body most tenaciously holds any alkaline salts that 
may still he present. A new source for the neutralization of the 
acid is then found in the ammonia, which would otherwise have 
been transformed into urea. 

While the greater portion of the sulphuric acid excreted in the 
urine is found in the form of mineral sulphates, about one-tenth of 
the total amount may be shown to be in combination with aromatic 
substances belonging to the oxy-group; most important among these 
are the salts of phenol, indoxyl, and skatoxyl. 

Indoxyl and skatoxyl, as will be shown later, are derived from 
indol and skatol, which, together with phenol, are formed during 
the process of intestinal putrefaction. Their amount increases and 
decreases with the degree of putrefaction, and hence serves as an 
index of its intensity. 

The mineral sulphates have been termed preformed sulphates in 
contradistinction to the others, which are known as conjugate or 
ethereal sulphates. In the following pages the former will be desig- 
nated by the letter A, the conjugate sulphates by the letter B y and 
the total sulphates as A — B. 

The amount of A + B excreted in the twenty-four hours by a 
normal individual varies between 2 and 3 grammes, the ratio of A 
to B being as 10 : l. 1 

From what has been said, it is apparent that the elimination of 
sulphates is largely dependent upon the degree of albuminous decom- 
position taking place in the tissues and fluids of the body, and hence 
to a certain extent upon the quantity of proteid material ingested, 
the mineral sulphates occurring in such small amount in the food as 
scarcely to affect the quantity excreted. Secondarily, the degree of 
intestinal putrefaction plays a role. The excretion of A -f B is thus 
increased by a diet rich in animal proteids ; the time after a meal, 
however, at which such an increase can be demonstrated varies 
greatly, depending essentially upon the time necessary for digestion. 
With a vegetable diet, on the other hand, the total sulphates will be 
found diminished. During starvation A + B is, of course, also 
diminished, this diminution affecting A especially ; but in some 
cases B may be considerably increased. 2 

An increase in the elimination of the total sulphates is observed, 
as would be anticipated, in all cases in which an increased tissue- 
destruction is taking place, as in the acute febrile diseases. It must 
be remembered, however, that the quantity excreted is then not 
always greater than during convalescence, the diet remaining the 

1 v. d. Velden, Virchow's Archiv, vol. vii. p. -'U3. 

2 Clare, Inaug. Diss., Dorpat, 1854. 



336 THE UBINK 

same. Here, as elsewhere, in urinary studies, it is necessary to dis- 
tinguish between a relative increase and an absolute decrease. In 
pneumonia and acute myelitis the highest figures have been observed, 
the increased elimination during the febrile period being especially 
marked : l 

Fever diet. Full diet. 



Fever. No fever. Xo fever. 

Pneumonia 3.51 gm. 1.47 gm. 2.25 gm. 

Acute myelitis 2.62 gm. 1.52 gm. 2.33 gm. 

During convalescence the excretion of the sulphates is diminished, 
a retention analogous to that of the chlorides and phosphates taking 
place. In contradistinction to the latter salts, it is in all probability 
not the mineral matter proper that is demanded by the body, but the 
sulphur-containing albuminous material. 

A considerable elimination of A — B has also been observed in 
leukaemia, in which an average of 2.46 grammes is excreted, as com- 
pared with 1.51 grammes by a healthy individual receiving the same 
amount and kind of food. In one case of acute leukaemia 5.8 
grammes were eliminated on the day precediDg death. 2 

In diabetes mellitus, diabetes insipidus, oesophageal carcinoma, 
progressive muscular atrophy, pseudohypertrophic paralysis, and 
eczema an increased elimination has likewise been observed, while 
in chronic renal diseases a diminished excretion is the rule. 

A study of the elimination of the conjugate sulphates and of the 
relation existing between A and B in disease is still more important 
than that of the total sulphates ; but in both cases the data available 
are scant}', and further observations are urgently needed. 

The conjugate sulphates, as would be expected, are increased in 
all cases of increased intestinal putrefaction. In coprostasis the 
result of carcinoma the ratio of the preformed to the conjugate sul- 
phates, normally 10, may diminish enormously. In one case, reported 
by Kast and Baas, it fell to 2, but rose to 7 and 8, and finally to 9.5 
and 15 after an artificial anus had been established. 3 I have myself 
observed a drop to 1.5 in a case of volvulus of ten days' standing. 
Biernacki 4 found an increase in the elimination of conjugate sulphates 
amounting to from 0.15 to 0.5 gramme pro die in cases of chronic 
parenchymatous nephritis, going hand in hand apparently with a 
decrease in the secretion of hydrochloric acid by the stomach ; the 
normal amount, according to his observations, varies from 0.1973 to 
0.2227 gramme. In one case B fell from 0.4382 to 0.1505 during 
the administration of hydrochloric acid, to increase again to 0.4127 
upon its discontinuance. 

1 P. Fiirbringer, Vircbow's Archiv, vol. lxxiii. p. 39. 

2 Ebstein, Deutsch. Arch. f. kliu. Med., vol. xliv. p. 346. 

3 Kast u. Baas. Munch, rued. Woch., 1888. 

4 Biernacki, Deutsch. Arch. f. klin. Med., vol. lxix. 



CHEMISTRY OF THE URINE. 337 

In accord with these observations are those of Wasbutzki and 
Kast. 1 The former found an increased elimination of B in eases of 
intense bacterial fermentation taking place in the stomach, while 
hydrochloric acid was either totally absent or present in greatly 
diminished amount. A diminished elimination was observed in cases 
of intense tornlar fermentation, hyperchlorhydria existing at the 
same time. In the absence of hydrochloric acid a normal or even 
a slightly diminished amount was observed in cases of intense acid 
fermentation, lactic acid and butyric acid being present in large 
quantities. By neutralizing the- gastric juice with large doses of 
sodium bicarbonate Kast was able to bring about a marked increase 
in the elimination of B, the ratio .1 : B having fallen from 10.3- 
16.1 to 2.9-6.1. 

Personal observations have led me to the same conclusion, so that 
the following rules may be formulated : 2 

1. A diminution in the secretion of hydrochloric acid is accom- 
panied by an increased degree of intestinal putrefaction. 

2. An increase in the secretion of hydrochloric acid is usually 
accompanied by a decrease in the degree of intestinal putrefaction. 

3. The degree of intestinal putrefaction may be measured directly 
by the elimination of the conjugate sulphates. 

(See also the chapter on the Aromatic Bodies.) 

In obstructive jaundice the excretion of B was likewise found to be 
increased, returning to the normal as soon as the permeability of the 
biliary passages had again become established. The total sulphates 
were found in diminished amount in cases of non-obstructive jaundice. 3 

In cases of diarrhoea A -f- B, as w T ell as B, is diminished, while 
A : B is increased. 

Of drugs, large doses of morphin, potassium bromide, sodium 
salicylate, and a ntifebrin appear to cause an increased elimination of 
the total sulphates, while alcohol slightly diminishes the excretion. 

Most important are the observations which have established a 
diminished excretion of the conjugate sulphates following inges- 
tion of the terpenes and camphor, Karlsbad and Marienbad water, 
which latter two, however, at first cause an increase. Kefir, in doses 
of from 1 to 1.5 liters pro die, has proved a most excellent remedy 
with which to combat intestinal putrefaction. Injections of tannic 
acid and of a saturated solution of boric acid apparently produce little 
effect unless the dose is so large as to cause symptoms of poisoning. 

Tests for the Sulphates in the Urine. — The detection of the 
preformed and the combined sulphates in the urine depends upon the 
fact that the sulphates of the alkalies are precipitated by barium 
chloride as insoluble barium sulphate, according to the equation : 

1 Kast, Festsch. z. Er6ft'nui»<r d. neuen allgem. Krankenhauses, Hamburg, 1889.. 
Wasbutzki, Arch. f. exper. Path. u. PharmakoL, vol. xxvi. 
I . E. Simon. Am. Jour. Med. Sci., 1895, vol. ex. 
3 Ziilzer, Unters. uber d. Semiol. d. Hams, Berlin, 1884. 

22 



338 



THE URIXE. 



K.,30, + BaCl 2 = BaSO, 



!KC1. 






In the urine the addition of barium chloride at the same time causes 
a precipitation of the phosphates. These must be kept in solution 
by the addition of an acid, acetic acid being employed for this pur- 
pose whenever the presence of the preformed sulphates is to be 
demonstrated ; hydrochloric acid is inadmissible, as it would cause 
decomposition of the conjugate sulphates and set free the sulphuric 
acid thus held. 

To test for the pre formed, sulphates, a few cubic centimeters of urine 
strongly acidified with acetic acid are treated with a few drops of a 
solution of barium chlo- 
ride, when in their pres- 
ence a cloud or a white 
^ precipitate of barium sul- 
/ phate will occur. 

To test for the conjugate 
sulphates j 25 c.c. of urine 
are treated with about the 
same volume of an alkaline 
barium chloride mixture (2 
volumes of a solution of 
barium hydrate and 1 vol- 
a Gooch filter. ume of a solution of barium 

chloride, both saturated at 
ordinary temperatures) and filtered after a few 
minutes, the preformed sulphates as well as the 
phosphates being thus removed. The filtrate is 
then strongly acidified with hydrochloric acid and 
boiled ; the occurrence of a precipitate is referable 
to conjugate sulphates. 

Quantitative Estimation of the Sulphates. 1 — 
The principle of the method employed is the same 
as that just described, the preformed sulphates con- 
tained in the urine forming an insoluble precipitate 
of barium sulphate when treated directly with 
barium chloride, while the combined sulphates do 
so only after having been decomposed with strong 
hydrochloric acid and the application of heat. In 
order to estimate the amount of preformed and 
conjugate sulphates, it is best to determine the 
total sulphates in one portion, and the combined sulphates in an- 
other, the difference between the two giving the preformed sulphates. 
Quantitative Estimation of the Total Sulphates. — One hundred c.c. 
of clear filtered urine are treated with 8 c.c. of hydrochloric acid 

1 E. Salkowski, Zeit. f. physiol. Ckeni., 1886, vol. x. p. 346 ; and Virchow's Archiv. 
1888, vol. lxxix. p. 551. 




A suction-funnel. 



CHEMISTRY OF Till-: URINE. 339 

(specific gravity 1.12) and heated to the boiling-point, when 20 c.c. 
of a hoi saturated solution of barium chloride are added. The 
mixture is kept on a water-bath until the barium sulphate has set- 
tled down and the supernatant fluid appears clear; this usually re- 
quires about a half hour. The precipitate is now filtered off through 
a Schleicher and Schiill filter, or a Gooch filter (Fig. 81), provided 
with a close-fitting plug of asbestos, the whole having been pre- 
viously dried and weighed, Care should be taken never to allow 
the filter to run dry, and small amounts of hot water must be added 
to the last cubic centimeters remaining, the final traces being placed 
upon the filter with the aid of a rubber-tipped glass rod. The pre- 
cipitate is washed with boiling water until a specimen of the wash- 
ings is no longer rendered cloudy, even on standing a few minutes 
after the addition of a drop of dilute sulphuric acid. Gum-like 
substances, as well as pigments, are removed by washing with hot 
alcohol (70 per cent.), and then filling the filter two or three times 
with ether. A suction apparatus is very convenient, but not neces- 
sary ; a simple glass tube, bent upon itself, will answer the purpose 
(Fig. 82). 

If a paper filter has been used, it is placed in a weighed platinum 
or porcelain crucible and ignited. The ash is then heated, at first 
moderately, and almost completely covered with the lid. It is then 
heated, only half covered, for from five to seven minutes, until the 
contents of the crucible are white. The crucible, when cooled, is 
placed in a desiccator and .weighed, the difference between the first 
and the second weighing giving the weight of the barium sulphate 
obtained from 100 c.c. of urine. 

A reduction of some of the sulphate usually takes place during 
the process of combustion, owing to the presence of organic matter, 
so that the weight obtained is actually too low. This error may be 
corrected in the following manner : the barium sulphate is washed 
into a small beaker with a small amount of water and titrated with 
a one-tenth normal solution of sulphuric acid, using phenol phthalein 
as an indicator. Each cubic centimeter of the one-tenth normal 
solution corresponds to 0.004 gramme of barium sulphate. The 
actual amount of sulphates contained in 100 c.c. of urine is ascer- 
tained by adding the figure thus found to that obtained by weighing 
(see below). 

Instead of correcting a- just described, the ash may be moistened 
with a few drops of a dilute solution of sulphuric acid ; then when 
heat is applied again any sulphide that may have formed is trans- 
formed into the sulphate. 

Quantitative Estimation of the Conjugate Sulphates. — One hun- 
dred c.c. of clear filtered urine are mixed with 100 e.e. of an alka- 
line solution of barium chloride (see above), the mixture being 
thoroughly stirred. After a few minutes it is filtered through a 



340 THE URINE. 

dry filter into a dry graduate to the 100 c.c. mark. This portion, 
corresponding to 50 c.c. of urine, is now strongly acidified with 
dilute hydrochloric acid and brought to the boiling-point. It is 
kept upon a boiling water-bath until the barium sulphate has settled 
and the supernatant fluid is clear. The precipitate is filtered off, 
washed, dried, and weighed, as described above. The weight thus 
obtained, multiplied by 2 and deducted from the amount found 
according to the first method, indicates the amount referable to the 
preformed sulphates. The molecular weight of BaS0 4 being 232.82, 
that of SO s 79.86, of H 2 S0 4 97.82, and of S 32, the figure express- 
ing the amount of H 2 S0 4 , S0 3 , or S, corresponding to 1 gramme of 
BaS0 4 , is found according to the following equations : 

232.82 : 79.86 : : 1 : x ; and x = 0.34301. .-. 1 gramme of BaS0 4 
= 0.34301 gramme of S0 3 . 

232.82 : 97.82 : : 1 : x ; and x = 0.42015. .-. 1 gramme of BaSo 4 
= 0.42015 gramme of H.,S0 4 . 

232.82 : 32 : : 1 : x ; and x = 0.13744. .-. 1 gramme of BaS0 4 = 
0.13744 gramme of S. 

To calculate results, it is only necessary to multiply the weight 
of the BaSO.by 0.34301, 0.42015, or 0.13744, in order to ascertain 
the amount of sulphuric acid contained in 50 c.c. of urine, in terms 
of S0 3 , H 2 SG 4 , or S, respectively. 

Neutral Sulphur. 

While the greater portion of the sulphur of the body is eliminated 
in an oxidized form, traces of non-oxidized sulphur bodies are like- 
wise found in every urine. They are collectively spoken of as the 
neutral sulphur of the urine, and under normal conditions constitute 
from 12 to 15 per cent, of the total sulphur. The relation existing 
between the oxidized and the neutral form is, however, inconstant, 
and varies with the character of the diet, the degree of the proteid 
metabolism, etc. 

Of the nature of the neutral sulphur bodies which occur in 
normcl urine, comparatively little is known. At the present time 
we are acquainted with only two substances belonging to this order, 
viz., certain sulphocyanides and cy stein, or a body which is closely 
related to it. The greater portion of the sulphocyanides is undoubt- 
edly derived from the saliva that has been swallowed and absorbed, 
while a smaller amount may be referable to the trace which is said 
to be present in normal, uncontaminated gastric juice. The origin 
of ei/steln, on the other hand, has not been definitely ascertained. 
Possibly it represents an intermediary product of the normal metab- 
olism of proteid material. Under normal conditions, however, the 
greater portion is certainly oxidized to sulphuric acid, and traces 
only escape to be eliminated as such. 



CHEMISTRY OF THE URINE. 341 

Whether or not fauro-carbaminic acid, which is a derivative of 
taurin, is a constant constituent of the urine, remains an open question, 
but is very probable. We know, as a matter of fact, that the amount 
of neutral sulphur undergoes a distinct diminution in animals when 
the bile is prevented from entering the intestinal canal by establish- 
ing an external fistula. Under pathological conditions a correspond- 
ing- increase is observed in eases of biliary obstruction, and the 
amount of neutral sulphur may then reach 40 per cent, of the total 
sulphur. 

Thiosulphates, which are normally present in the urine of dogs 
and cats, do not occur in human urine under normal conditions. 
That they may be present in disease has been shown by Stri'nnpell, 
who found them in a case of typhoid fever. Further observations, 
however, are wanting. 

Another sulphur body belonging to this class, which Abel dis- 
covered in the urine of dogs, and which appears to be identical with 
ethyl sulphide, has not as yet been found in the urine of man. 

The greatest increase in the amount of the neutral sulphur is 
observed under certain conditions associated with the appearance 
of cyst in. Normally this is never present in the urine, while 
traces of cystein, or a closely related substance, as I have already 
stated, are found. The origin of cystin, like that of cystei'n, is 
not definitely known, but the evidence seems to point to the liver 
as the probable seat of its formation. According to Baumann 
and v. Udranszkv, its appearance in the urine is closely con- 
nected witL the formation of certain diamins, viz., cadaverin, 
putrescin, and a third diamin which is probably identical with saprin 
or neuridin. As these diamins were hitherto supposed to result 
only from the action of certain specific bacteria upon albuminous 
material, cystinuria was regarded as evidence of a definite infections 
process. It is to be noted, however, that cystin itself does not 
occur in the feces, and that diaminnria does not necessarily accom- 
pany the cystinuria. As the result of personal observations I have 
been led to the conclusion that a causal connection does not exist 
between the two conditions, and that the diamins in question can 
be produced in the body-tissues directly without the intervention of 
micro-organisms. Like Moreigne, I incline to the belief that 
cystinuria i- essentially a metabolic anomaly, and the result of defi- 
cient oxidation-processes taking place in the body. 

The amount of neutral sulphur which may be met with in cystin- 
nria is subject to wide variation, but not infrequently exceeds :)<) 
per cent, of the total sulphur. As a general rule, the amount of 
cystin eliminated in the twenty-four hours is less than <>.•"> gramme. 
At times, however, larger quantities are found, and on one occasion 
I obtained more than 1 gramme. Clinically it is of interest in so far 
a- it- continued production may give rise to the formation of calculi. 



342 THE URINE. 

Unless cystin occurs as a deposit, its presence will scarcely be 
suspected. The substance, however, may occur also in solution, 
and it not infrequently happens that attention is first drawn toward 
its existence in this state o^ing to the marked odor of hydrogen 
sulphide, which such urines develop on standing (see Hydrothion- 
uria). If acetic acid is then added in excess, 'the characteristic 
hexagonal plates may crystallize out. The same result is obtained 
also by allowing the urine to undergo ammoniacal decomposition, 
as cystin is insoluble in solutions of ammonium carbonate. 

Chemically, cystin may be regarded as the disulphide of amido- 
ethylidene lactic acid, and, according to Baumann, is represented 
by the formula 

OH 3 CH, 

I /NH 2 NH aX I 



I ^ 




COOH COOH. 

Its relation # to cystein is further represented by the equation 

CH 3 

NH, I 

+ 2H = 2 >C 

HS X J 

COOH. 
Cystin. Cystein. 

and I have pointed out elsewhere that cystein may be derived from 
phenyl-alanin, which latter occurs as a normal decomposition-prod- 
uct of the proteid molecule. Since putrescin, moreover, may be 
obtained from ornithin, and this from arginin, which in turn is 
formed during decomposition of the protamin radicle of the albu- 
minous molecule, we can readily imagine that both cystin and diamins 
will result if for any reason the oxidation-processes of the body are 
seriously impaired. The relation between phenyl-alanin — phenyl- 
tf-amido-propionic acid — and cystein is represented by the formulae: 

CH 3 — CH(NH 2 )— COOH CH 3 — C(NH 2 )HS — COOH. 

Phenyl-alanin. Cystein. 

Cystin crystallizes in hexagonal plates which are quite characteristic, 
and not likely to be confounded with other crystalline elements that 
may be present in urinary sediments. If doubt should arise, their 
solubility in ammonia and hydrochloric acid, and their insolubility 
in acetic acid, water, alcohol, and ether, will lead to their identifi- 
cation. 

The quantitative estimation of cystin is rather unsatisfactory, as 
no method is known which yields reliable results. On the whole, it 
is perhaps best to determine the. neutral sulphur, and to refer the 
increase beyond its normal value to the presence of cystin. 

Quantitative Estimation of the Neutral Sulphur in the Urine. — In 
100 c.c. of urine the oxidized sulphur, viz., the mineral and the 



CHEMISTRY OF THE URINE. 343 

conjugate sulphates, are estimated as described on page 338. In 
the second portion the total sulphur then is determined, the differ- 
ence indicating the amount of the neutral sulphur. 

To determine the total amount of sulphur, 100 e.e. of urine are 
treated with 12 grammes of a mixture of sodium and potassium 
carbonate (11 : 14), and evaporated to dryness in a nickel crucible. 
The residue is fused thoroughly, allowed to cool, and extracted with 
hut water. The carbonaceous residue is filtered off and the filtrate and 
washings are treated with a few crystals of potassium permanganate. 
After heating for about fifteen minutes (more potassium permanga- 
nate should be added if during this time the solution becomes de- 
colorized, when heat is again applied for fifteen minutes), concentrated 
hydrochloric acid is added until the reaction is distinctly acid. This 
solution is then brought to the boiling-point and treated with about 
20 c.c. of a saturated solution of barium chloride. The barium 
sulphate thus formed is then collected and weighed as described on 
page 339. The difference between this result and the first indicates 
the amount of neutral sulphur. 

Literature. — E. Salkowski, Virchow's Archiv, vol. lxvi. p. 313, and vol. exxxvii. 
p. 381. Goldmann u. Baumann, " Zur Kenntniss der Schwefelhaltigen Verbindungen 
des Harns,*' Zeit. f. physiol. Ohem., vol. xii. p. 254. E. Salkowski, Virchow's Archiv, 
vol. lviii. j). 4H1. J. Munk, Ibid., vol. lxiv. p. 354; and Dentsch. nied. Woch., 1877, 
No. 46. O. Schiniedeberg, " Ueber das Vorkoramen von Unterschwefliger San re im 
Harn." Arch. d. Heilk., vol. viii. p. 425. A. Striimpell, Ibid., vol. xvii. p. 390. J.Abel, 
" Ueber das Vorkoramen von Ethylsulfid im Hundeharn," etc., Zeit. f. physiol. Chcm., 
vol. xx. p. 253. (See also Cystinuria and Hydrothionuria.) 

Urea. 

Urea is by far the most important nitrogenous constituent of the 
urine, and normally represents from 85 to 86 per cent, of the total 
amount of nitrogen which is eliminated by the kidneys. Chemically, 
it may be regarded as carbamide — l. e., as the amide of carbonic 
acid — and is represented by the formula 

CO< 

MI, 

It is thus a comparatively simple substance, and the question natu- 
rally arises : In what relation does urea stand to the highly complex 
albuminous molecule from which it is derived ? Numerous hypoth- 
eses have been offered to explain this problem, but, although we are 
in possession of a number of very suggestive data, ;i final answer to 
the question cannot be given at the present time. In all Likelihood, 
however, the urea may originate from the albumins in different ways. 
During the hydrolytic decomposition of the albumins by acids 
and alkalies bodies are constantly formed which belong to the cla<s 
of amido-acids, and these bodies Sehultzen and Nfencki have accord- 
ingly regarded as intermediary products in the formation of urea 



344 THE URINE. 

within the tissues also. The most important members of this 
group are, leucin, ty rosin, glycocoll, asparaginic acid, and gluta- 
minic acid. They are represented by the formulae : 

CH 2 <^ — Glycocoll, or amido-acetic acid. 

XSOOH 
CH 3X 

^CH.CH 2 .CH.NH 2 .COOH — Leucin, or amido-capronic acid. 
CH 3 

/OH(l) 

x CH 2 .CH(NH 2 ).COOH(4) — Tyrosin, or para - oxy - phenyl - amido - propionic 

acid. 

COOH.CH 2 .CH (NH 2 ). COOH — Asparaginic acid, or amido-succinic acid. 

COOH.CH (NH 2 ). CH 2 .CH 2 .COOH— Glntaminic acid, or amido-glutaric acid. 

When introduced into the mammalian organism from without, the 
nitrogen of these bodies appears in the urine, to a large extent at 
least, as urea. An analogous formation from the tissue-albumins 
was hence also supposed to occur, but nothing is known of the 
manner of their transformation in the body into urea. Different 
possibilities suggest themselves. It is thus conceivable that cyanic 
acid — CONH — may be produced as an intermediary product, and 
that urea then results through the interaction of two molecules of 
the substance, in statu nascendi, according to the equation 

/NIL, 
CONH + CONH + H 2 = CO< " + C0 2 

X NH 2 

On the other hand, a transformation of the amido-acids into the 
ammonium salts of the fatty acids standing next in order in the 
downward scale may also be imagined. Ammonium carbonate 
would then result, which, through loss of water, could give rise to 
urea. In the case of glycocoll this transformation could be repre- 
sented by the following equations : 



C0 2 



According to Drechsel, further, the amido-acids are transformed into 
carbonic acid, two molecules of which then unite to form urea, 
carbon dioxide, and water : 

y NH 2 /NH 2 /NH. 

CO< + CO< = CO< " + C0 2 + H 2 

x OH x OH \NH a 



(1) 


CH 2 .NH 2 .COOH + 20 = 
Amido-acetic acid. 


= NH 4 .COOH + C0 2 

Ammonium 
formate. 


(2) 


2NH 4 .COOH 

Ammonium 
formate. 


+ 20 = 


= (NH 4 ) 2 C0 3 +H 2 0- 

Ammonium 
carbonate. 


(3) 


(NH 4 ) 2 CO a 




/NH 2 

= C0< + 2H 2 

X NH 2 



CHEMISTRY OF THE URINE. 345 

The hypothesis of Schultzen and Nencki regarding the origin of 
urea from amido-acids is supported by the fact that these substances, 
when introduced into the mammalian organism from without, arc 
largely transformed into urea during their passage through the body. 

It is known, moreover, that in certain diseases, such as acute yel- 
low atrophy, the urea may disappear from the urine almost entirely, 
its place being taken by leucin and tyrosin. In other conditions, 
however, in which the formation of urea is even more seriously 
impaired, lencin and tyrosin do not appear in the urine, and there 
is a growing tendency among physiologists at the present time to 
abandon the older view of Schultzen and Nencki, and to explain 
the apparently vicarious elimination of the amido-acids in acute 
yellow atrophy upon a different basis. Lencin and tyrosin are 
normally scarcely ever encountered in the mammalian organism, 
and the opinion now prevails that the greater portion of the nitro- 
gen which is to be eliminated from the body leaves the tissues as 
the ammonium salt of paralactic acid. In the liver this is trans- 
formed into ammonium carbonate, from which urea then results 
synthetically, with the intermediary formation of ammonium car- 
bamate. This transition may be represented by the equations : 

/NH 2 

(1) (NH 4 ) a CO, = C(\ + H 2 

X>.NH 4 

Ammonium Ammonium 

carbonate. carbamate. 

.Nil, ,NH 2 

(2) CO< =CO< +H 2 

x O.NH 4 X NH 2 

Ammonium Urea, 

carbamate. 

This hypothesis has much in its favor. We thus find that after 
extirpation of the liver in geese the uric acid, which in birds plays 
the same part as the urea in mammals, disappears, and is largely 
replaced by ammonium lactate. In diseases of the liver, moreover, 
in which an extensive destruction of the parenchyma is taking place, 
as in some cases of acute yellow atrophy, in phosphorus poisoning, 
etc., the elimination of una is diminished, and in its place a cor- 
responding amount of ammonia in combination with lactic acid is 
found. In dogs in which the liver has been in part excluded from 
the general circulation by the establishment of an Eck-fistula, and 
in which the hepatic artery has at the same time been ligated, the 
elimination of urea is much diminished, while that of ammonia 
increases rapidly so soon as the first symptoms of illness appear in 
the animals. In such cases, owing to the incomplete isolation of 
the organ, ammonium carbamate appears in the urine, instead of 
ammonium lactate. From these observations it is apparent also 
that the synthesis of urea takes place in the liver. This is further 



34C TEE URINE. 

proved by the fact that on transfusion of isolated livers : logs 
with blood to which ammonium carbonate or ammonium lactate 
has been added, urea is formed as a result. In other organs of the 
body this synthesis apparently does not occur, but there is evidence 
t : show that at least a small amount of urea originates elsewhere 
within the body through pr esses f hydrolysis. This amount, 
however, is unquesti irably slight. That a fraction, moreover, is 
formed from uri: and in the last instance from the xanthin- 

es through pi aesses : xiclation, can scarcely be doubted, but 
this transformation apparently als takes place in the liver. 1 

Before going on t< nsi ration of the quantitative excretion 

of urea in health and disease it will be well to form an idea of its 
ultimate sources. To this end, the theory of Voit- should be 
recalled, according to which, albuminous material exists in the body 
in r lifieronf forms — . . - reanized albumin, which is built 
np in the form of ihe tissues of the body, and as unorganized albu- 
min or circulating albumin, which must be regarded in a manner as 
a reserve, to be used in tissue-repair or to be broken down if not 
used, and to he replaced by the proteids ingested with the next meal. 
It may hence be said that, as in the case of the mineral constituents 
of the urine, the area is referable on the one hand to the proteids of 
the food, and on the other to the proteids of the body-tissues. It 
is ear then that elimination of urea will continue during starvation. 
It has been stated that 84 to 86.6 per cent, of all the nitrogen 
eliminated in the urine is in the form of urea, the remaining ISA 
per cent, being excrete:! as uric acid, hippuric acid, kreatinin, 
xanthin- bas ->. etc. It might hence be supposed that an accurate 
: : rhe degree of tissue-destruction could be formed from a 

qnantitative estimation of urea. This, however, is not the <: - 
especially in pathological conditions, as the quantitative relations 
existing between the excretion of urea and the remaining nitrogenous 
: -tituents are subject to wide variation. In acute yellow atrophy, 
for example, as pointed out above, urea may disappear entirely from 
the urine, the nitrogen being eliminated in the form of other eoni- 
poua - henev . it becomes lesirable then to gain an accurate 

b sight into the degi : : :: -destruction or proteid-assimilation 
— in other words, into the nitrogenous metabolism — taking place in 
the body, it is necessary to resort to a quantitative determination of 

'7 origin of n. X Sd - ILK Z t :'. Biol.. 1872, vol. viii. p. 1'24. 

I - 1379, voLi I v. Knieriem. Zeit. f. Biol-, 

1874, v ." LS - jrsiol. 1877, toI. L p. 38. Hopre- 

- - - Physi I 188] - Di - vol. xv. p. 

s^i. 169 and 18 " M. Halm. ¥. Massen, 1L Kenda 

J. Pawlow, • • L - Sei. St. Petersburg 1892, vol. i 

- _ - Path. a. Fhanns kol 188S 

- - 1884 rol scviL ] 14 Mlnkows 

L S ■ ' - Arch. i. evper. Path. 

n. Pharmakol., 188 

- _ Stiofl - I. Eraahrun^. Herman's Handbueh d. 

Physi 1881 roL vi. I. p. 301. 



CHEMISTRY OF THE URINE. 347 

the total amount of nitrogen excreted by the kidneys ; the quantity 
found is then conveniently expressed in terms of urea. At the 
same time it is customary to express the amount of proteid tissue 
which is destroyed, as muscle-tissue, as this serves as a lair type of 
body-tissue in general. 

A- 100 grammes of lean muscle-tissue contain about 3.4 grammes 
of nitrogen, corresponding to 7.286 grammes of urea, 1 gramme of 
the latter is equivalent to 13.72 grammes of muscle-tissue. It is, 
hence, only necessary to multiply the quantity of urea eliminated in 
the twenty-four hours, corresponding to the total amount of nitrogen 
found, by 13.72, in order to obtain an idea of the exteut of albu- 
minous destruction taking place in the body. If accurate results 
are desired, it becomes necessary to determine also the amount of 
nitrogen eliminated in the feces, a knowledge of the quantity in the 
food ingested being, of course, presupposed. 

With all these data given, the nitrogenous metabolism of the body 
can be accurately controlled. 

Example. — A patient eliminates 50 grammes of urea in twenty- 
four hours ; these 50 grammes correspond to 50 X 13.72 — L e., 686 
grammes of lean muscle-tissue ; on the other hand, he ingests an 
amount of nitrogenous material corresponding to only 10 grammes 
of urea, equivalent to 10 X 13.72 — i.e., 137.2 grammes of muscle- 
tissue. The difference between the amount ingested and that ex- 
creted in this ease — i. c, 548.8 grammes — must be referable to the 
destruction of organized albumin. 

When the amount of nitrogen eliminated is equivalent to. that in- 
gested, nitrogenous equilibrium is said to exist. A healthy person is 
approximately in this condition. 

It has been pointed out that during starvation urea is still elimi- 
nated from the body, although in diminished amount. The question 
now arises. What happens if at this time an amount of nitrogenous 
food is given which corresponds exactly in amount to that elimi- 
nated? Under such conditions an increased elimination of nitrogen 
takes place, all of the nitrogen ingested, in addition to that resulting 
from a breaking down of body-tissues, being excreted. The amount 
of nitrogen referable to the latter source, however, is somewhat less 
than that eliminated in the total absence of food. Unless starvation 
has been pushed too far, the body accommodates itself to the amount 
of food thus given and nitrogenous equilibrium is restored, [f more 
food is allowed, an increased elimination results, which again Leads to 
a condition of nitrogenous equilibrium, different levels, so to speak, 
being possible. This is well illustrated by comparing the condition 
of the poorly nourished North German laboring population with 
that of the well-fed merchants, the excretion of urea in the former 
amounting to 17.5 to 33.5 grammes, and in the latter to 30 or < \\\ 
40 grammes. 



348 THE URINE. 

It is apparent, then, that the elimination of urea, and of nitrogen 
in general, is subject to great variation, depending upon the amount 
ingested and that resulting from tissue-destruction, which in turn is 
influenced largely by the body-weight. A statement in figures 
expressing the daily elimination of urea and of nitrogen would, 
hence, be of very little value, especially in pathological conditions, 
in which the amount of nitrogen ingested is frequently very small. 
The elimination of nitrogen should hence always be compared with 
the amount ingested, for which purpose the tables of Konig 1 will 
be found most convenient. At the same time it must be remem- 
bered that not all the nitrogen taken into the body as food under- 
goes resorption, and that a variable amount, which in disease may 
be considerable, is eliminated with the feces, so that in accurate work 
this nitrogen also must be taken into account. In order to obviate 
the tedious estimation of nitrogen in the feces, it has been proposed 
to determine the standard amount of urea which should appear in 
the urine of a healthy person under different forms of diet. Such 
experiments, of course, presuppose the control-person to be in a 
condition of nitrogenous equilibrium, which, from what has been 
said above, is readily accomplished, as the human body adapts itself 
with ease to different forms of diet. In private practice, however, 
such a procedure would be difficult, but here approximate results 
can be obtained from a parallel estimation of the chlorides. In 
health the elimination of the chlorides may be placed at about one- 
half of the urea. Whenever the nitrogen resulting from tissue- 
destruction is in excess of that referable to the proteids ingested, this 
relation between the excretion of chlorides and urea will be disturbed, 
as the tissues of the body contain very little sodium chloride. When- 
ever the amount of urea is in excess of the normal amount of chlo- 
rides, as indicated above, an increased tissue-destruction may be in- 
ferred, and vice versa. If, on the other hand, the chlorides are present 
in diminished amount, the conclusion may be drawn that a retention 
of albumins is taking place in the body ; this is observed frequently 
during convalescence from acute febrile diseases. 

An increase in the amount of urea, and, as a matter of fact, of all 
the nitrogenous constituents, is observed especially in the acute 
febrile diseases, notwithstanding the diminished ingestion of nitrog- 
enous material, and is due to the greatly increased tissue-destruc- 
tion. 2 An excretion of 50 grammes or more is here frequently 
observed. Formerly it was thought that the fever itself was re- 
sponsible for this increased elimination. But this view became 
untenable when it was shown that the excretion of urea in the 
beginning of a febrile attack is not proportionate to the height 

1 J. Konig, Chetnie d. menschlichen Nahrungs u. Genussmittel, Berlin, 1893. 

2 Vogel, Zeit. f. rationelle Med., N. F., vol. iv. p. 362. Huppert, Arch. d. Heilk., vol. 
vii. p. 1. Lobisch,Wien. med. Presse, 1889, vol. xxxix. p. 1521. Huppert u. Eiesellt, Arch, 
d. Heilk., vol. x. p. 329. Bauer u. Kiinstle, Deutsch. Arch. f. klin. Med., vol. xxiv. p. 53. 



CHEMISTRY OF THE URINE. 349 

of the temperature, reaching its highest point only when the fever 
has been continuous for several days. Still larger amounts, more- 
over, may be eliminated when the fever is abating. Similar obser- 
vations have since been made. An increased elimination of nitrogen 
may also be noted in almost every ease of ague preceding the onset 
of the fever. The latter, therefore, cannot be the only factor which 
causes the increased excretion of urea, and it has been suggested that 
the cells of the body have lost the power of taking up nitrogen. 
The question, however, whether this is dependent upon the increase 
in temperature or the action of certain toxic substances circulating 
in the blood, or upon both, still remains unanswered. 

The large increase in the elimination of nitrogen in febrile dis- 
eases is especially striking in those which end by crisis. This is 
notably the case in pneumonia, in which it may persist for two or 
three days after the occurrence of the crisis. The assumption of an 
underlying insufficiency on the part of the cells furnishes a very sat- 
isfactory explanation for the continued increased elimination of urea. 
An increase beyond the amount eliminated during the febrile stage 
is possibly owing to a retention analogous to that of the mineral 
constituents of the urine. 

Apparently, the only exception to the rule that the amount of 
urea is increased in acute febrile diseases, is acute yellow atro- 
phy, in which the excretion of urea is not only greatly diminished, 
but may cease altogether, its place being taken by other nitrogenous 
bodies, such as ammonium lactate, leucin, and tyrosin. 

Among afebrile diseases in which an increased elimination of urea 
has been noted, may be mentioned the ordinary forms of diabetes 
mellitus, in which the highest figures have been obtained, viz., 150 
grammes or more pro die. This is, in all probability, explained, in 
part at least, by the ingestion of excessive amounts of proteid food 
by such patients, but carefully conducted experiments seem to show 
that a not inconsiderable portion of the urea is directly referable to 
increased tissue-destruction. The cases described by Hirschfeld, 1 
however, which will be considered later on, form an exception to 
this rule. 

An increase is observed also in dyspnoeic conditions, and particu- 
larly in pneumonia, in which it is most marked on the day following 
the greatest difficulty in breathing. These observations, however, 
are not free from objections, as an increase has also been noted in 
conditions of apnoea. 

A moderate increase has been found in cases of pernicious anaemia, 
in severe cases of leukaemia, scurvy, minor chorea, and paralysis 
agitans. Observations made in cases of hystero-epilepsy have given 
rise to conflicting results. It is claimed, on the one hand, that the 

1 F. Hirschfeld, " Ueber eine neue klin. Form d. Diabetes,'' Zeit. f. klin. Med., vol. 
xix. pp. 294 and 325. 



350 THE URINE. 

excretion of urea is diminished following convulsive seizures of a 
hystero-epileptic nature, in contradistinction to an increased eliruina- 
tion following true epileptic attacks. 

In cases of functional albuminuria associated with an increased 
elimination of uric acid or oxalic acid, or of both, as well as in 
numerous cases of gastro-intestinal disease, I have observed an in- 
creased elimination of urea, and believe that in the treatment of these 
diseases a systematic study of the excretion of nitrogen is of funda- 
mental importance. 

Of drugs, an increased elimination is produced by coffee, caffein, 
morphin, codein, ammonium chloride, sodium and potassium chlo- 
rides, lithium carbonate, following the ingestion of large amounts of 
water, etc. The data concerning the action of quinin, salicylic acid, 
cold baths, etc., are conflicting. A large increase has been observed 
in cases of phosphorus poisoning. 

Electricity also appears to exert a marked influence upon the 
excretion of urea, producing an increased elimination. 

The diminished elimination of urea observed in certain diseases of 
the liver, 1 notably in acute yellow atrophy, carcinoma, cirrhosis, and 
even in Weyl's disease, is of especial interest, and is in perfect 
accord with the theory that the liver is the main seat of its pro- 
duction. 

As has been stated, urea may disappear altogether from the urine 
in acute yellow atrophy and also in Weyl's disease, notwithstanding 
the frequently not inconsiderable degree of fever. In cirrhosis, 
hyperemia of the portal system has been thought to cause the dimi- 
nution, which may be increased further in some cases by the occur- 
rence of ascites. In short, the factors which may be regarded as 
causing a diminished elimination of urea in hepatic diseases may be 
summarized under the following headings : 

1. Destruction of hepatic parenchyma. 

2. Diminished velocity of the flow of blood through the liver. 

3. Insufficient excretion of bile and coincident digestive disturb- 
ances. 

Whenever there is disease affecting that portion of the renal 
parenchyma which is concerned especially in the elimination of urea, 
a diminished amount will, of course, be met with, and carefully con- 
ducted observations upon the excretion of the various urinary 
constituents are here of considerable value from a diagnostic as 
well as a therapeutic standpoint. As the glomeruli of the kid- 
neys are mainly concerned in the elimination of water and salts 
from the blood, and as the striated epithelium of the convoluted 
tubules appears to provide for the excretion of urea, the elimination 

1 Hallerworden, Arch. f. exper. Path. u. Pharmakol., vol. xii. Weintrand, Ibid., 
vol. xxxi. Stadelniann, Deutsch. Arch. f. kliii. Med., vol. xxxiii. Fawitzki, Ibid., 
vol. xlv. Frankel. Berlin, klin. Woeh., 1S78 and 1892. v. Noorden, Lehrbueh d. Path, 
d. Stoftwechsels, p. 287. 



CHEMISTRY OF THE URINE. 351 

of a fair amount of the latter with a diminished elimination of salts, 
the phosphates being of especial interest, as they are derived to 
a Large extent from albuminous material, would point more particu- 
larly to glomerular disease. On the other hand, a fair excretion of 
phosphates and a diminished excretion of urea would be indicative 
of tubular disease. Whenever glomeruli and tubuli contorti are 
equally diseased an insufficient elimination of both phosphate- and 
urea will be observed. 

While, as a rule, the excretion of urea is greatly increased in 
diabetes mellitus, certain cases, which have been elaborately described 
by Hirschfeld, 1 must be excepted. His researches have established 
beyond a doubt that the resorption of nitrogenous material from the 
intestines may be very much below normal, and with it the elimina- 
tion of urea. Upon these grounds he has advocated the recognition 
of a distinct form of diabetes, which is characterized by a com- 
paratively rapid course, the occurrence of colicky abdominal pains 
before or at the onset of the diabetic symptoms proper, the existence 
of pancreatic lesions in a certain proportion of the cases, a more 
moderate degree of polyuria, etc. 

In mental diseases a diminished excretion of urea has been ob- 
served in melancholia and in the more advanced stages of general 
paresis, while an increase is associated with the increased ingestion 
of food during the first stage of profound dementia. 

Following epileptic, cataleptic, and hysterical seizures, as well as 
in pseudohypertrophic paralysis, a decrease has been noted by some 
observers. 

The diminished excretion observed in Addison's disease has also 
been regarded as of nervous origin. 

All forms of chronic, non-progressive anaemia are associated with 
a decrease, as are also osteomalacia, impetigo, lepra, chronic rheu- 
matism, etc. In chronic lead poisoning the elimination of urea may 
be greatly diminished. 

Little is known of the influence of drugs in bringing about a 
diminished excretion of urea. 

In conclusion, the relation existing between phosphatic excretion 
and that of nitrogen should be especially noted, for a consideration 
of which, see page 329. 

Properties of Urea. — Urea crystallizes in two forms, viz., in long, 
fine, white needles if rapidly formed, or in long, colorless, quadratic 
rhombic prisms when allowed to crystallize gradually from itssolutions. 

At 100° C. it begins to show signs () f decomposition ; at 130° to 
l-°>2° C. it melts ; and when heated still further it is decomposed into 
cyanic acid and ammonia, of which the former is immediately trans- 
formed into its polymeric compound, eyanuric acid. The reaction 
which take- place is represented by the equations : 

1 Loo. cit. 



352 



THE URINE. 



/NH 2 

(1) C0< =CONH + NH 3 . 

\NH 2 

(2) 3C0NH = C 3 3 N 3 H 3 . 

Biuret is formed as an intermediary product during this decom- 
position, 2 molecules of urea yielding 1 molecule of ammonia and 
1 molecule of biuret, as represented in the equation 



CO< 



co< 



NH 2 

^NH 2 
.NIL 



NH Q 



CO 



,NH, 



NH + NH, 



CO 



X NH 2 



As this substance, obtained on dissolving the residue remaining after 
all the ammonia has been driven off by careful heating, yields a 
beautiful reddish-violet color when a drop or two of a very dilute 
solution of cupric sulphate is added to its solution alkalinized with 
sodium hydrate, this reaction may be employed as a test in the 
detection of urea (Biuret test). 

Urea is readily soluble in water, fairly so in alcohol, and insoluble 
in anhydrous ether and benzol. The aqueous solution of urea is 
neutral in reaction, but this substance combines with acids, bases, 
and salts to form molecular compounds. 

Of special interest are the compounds of urea with nitric acid, 
oxalic acid, and mercuric nitrate. 

Urea nitrate, CON 2 H 4 .HNO s , crystallizes in two different forms : 
in thin rhombic or six-sided colorless plates, which are frequently 



Fig. 83. 




Urea nitrate crystals. (Krukenbueg, after Kuhne.) 

observed arranged like shingles one on top of the other when rapidly 
formed (Fig. 83), while larger and thicker rhombic columns or plates 
are obtained if the process of crystallization is allowed to proceed 
more slowly. Urea nitrate is readily soluble in distilled water, while 



CHEMISTRY OF THE URINE. 



353 



in alcohol and in water containing nitric acid it dissolves with 
difficulty. Upon heating, it evaporates without leaving a residue. 

Urea oxalate, CK >N_. 1 1 ,.(\I \X ),, crystallizes in rhombic or six-sided 
prisms or plates (Fig. 84), which are less soluble in water than the 
nitrate ; in alcohol and in water containing oxalic acid it is only 
imperfectly soluble. 

Fig. 84. 




Urea oxalate crystals. (Krukenberg, after KVhne.) 

With mercuric nitrate urea forms three different compounds, accord- 
ing to the concentration of the two solutions, viz., (COX.,H 4 )Hg.,(N0 3 ) 4 , 
(CON 2 H 4 ).Hg3(N0 3 ) 6 , and (CON 2 H 4 ) 2 .Hg(X0 3 ) 2 + 3HgO. The lat- 
ter compound is of special importance, as Liebig's quantitative esti- 
mation of urea was based upon its formation. It results Avhen a 
2 per cent, solution pf urea is treated with a dilute solution of mer- 
curic nitrate, the reaction taking place according to the equation 

2COX 2 H 4 - 4IIg (NO s ) a + 3H a O = [2(COX 2 H 4 ) 2 Hg(XO,) 2 + 3HgO] + 6HN0 3 . 

Very important is the behavior of urea when treated with a solu- 
tion of sodium hypochlorite or hypobromite, the most usual method 
of estimating urea being based upon this reaction, which may be 
represented by the equation 

COX 2 H 4 -J- 3NaOBr = 3NaBr + 2X+C0 2 + 2H 2 0. 

In the chapter on Reaction it was pointed out that urine gradually 
undergoes ammoniacal decomposition when exposed to the air, 
and that this process is due to the action of a non-organized ferment ; 
the ammonia is liberated according to the equation 



00 



1 1 1 1 1 

Nil 



II<) = 2XH :J ^C0 2 . 



This decomposition may also be effected by heating a watery solu- 
tion of urea in a sealed tube to 100° C 



2:: 



354 THE URINE. 

Separation of Urea from the Urine. — Fifty to 100 c.c. of 
urine are evaporated to a syrupy consistence upon a water-bath, and 
extracted with 100 to 150 c.c. of strong alcohol, by rubbing up the 
residue, while still hot. with the alcohol. Upon cooling, the mixture 
is filtered, the alcohol evaporated, and the residue treated with pure 
cold nitric acid. Urea nitrate then separates out either immediately 
or on standing. After twenty-four hours the crystalline mass is 
collected on a muslin filter, well strained, and freed from liquid by 
placing it upon plates of clay. The material is then dissolved in 
hot water, and the solution, if strongly colored, gently warmed with 
animal -charcoal and filtered. This solution is neutralized with 
barium carbonate, and rendered alkaline with barium hydrate. The 
urea nitrate is thus decomposed, barium nitrate and urea being 
formed : 

20ON a H 4 .HNO 3 +Ba0O 3 =20ON a H 4 + Ba(NO s ) a - H.,0. 

The barium is now removed by passing a stream of carbon dioxide 
through the solution and filtering off the precipitate. The filtrate 
is evaporated until any barium nitrate still remaining crystallizes 
out. This is removed by decantation, when upon further evapora- 
tion the urea crystallizes out, and may be dried between layers of 
filter-paper and recrystallized from 95 to 98 per cent, alcohol. The 
crystals thus formed may now be subjected to further tests. To this 
end. a few drops of an aqueous solution are added to a few cubic 
centimeters of a sodium hypobromite solution, when in the presence 
of urea bubbles of gas will be given off. "With a solution of sodium 
hypochlorite the same result may be obtained, but in this case the 
evolution of gas takes place only upon the application of heat. The 
formation of biuret may also be demonstrated by carefully melting 
a few of the crystals in a test-tube, dissolving the residue when 
cool in a little water, and alkalinizing the solution with a little 
sodium hydrate ; upon the addition of a dilute solution of cupric 
sulphate a beautiful reddish- violet color will develop, owing to the 
presence of biuret. 

The addition of oxalic or nitric acid to a solution of urea will 
give rise to the formation of urea nitrate and oxalate, as described 
above. 

This latter test may very conveniently be made under the micro- 
scope. A drop of the concentrated solution is placed upon a slide, 
covered, and a drop of pure nitric acid added from the side. Crystals 
of urea nitrate will then be seen to separate out, and may be recog- 
nized by their characteristic shingle-like arrangement (see Fig. 83). 

When a urine is very rich in urea the mere addition of nitric acid 
will cause a more or less abundant precipitation of urea nitrate, and 
with this simple test an idea may even be formed of the amount 
present. An appearance of hoar-frost is thus noted when not less 



CHEMISTRY OF THE URINE. 355 

than 25 grammes are present in the liter, while the formation of 
spangles of urea nitrate requires the presence of at least 45 grammes, 
ami an abundant sediment occurs when 50 grammes or more are 
present. 

Quantitative Estimation of Urea. — Hypobromite Method. — The 
method most commonly used in the clinical laboratory is the one 
based upon the decomposition of urea into carbon dioxide and nitro- 
gen in the presence of sodium hypobromite. The reaction takes 
place according to the equation 

OON a H 4 -f 3NaOBr = NaBr + C0 2 + 2H 2 + 2N. 

The carbon dioxide thus formed is absorbed by an excess of sodium 
hydrate added to the hypobromite solution, while the nitrogen is set 
free, and can be collected and measured ; the determination of the 
corresponding amount of urea is then a simple matter. 

The only solution that is necessary is one of sodium hypobromite 
containing an excess of sodium hydrate. A 30 per cent, solution 
of the latter should be kept on hand and the sodium hypobromite 
solution prepared when required. To this end, 70 c.c. of the sodium 
hydrate solution are diluted with 180 c.c. of water and treated with 
5 c.c. of bromine in a bottle provided with a ground-glass stopper, 
the mixture being thoroughly shaken until every trace of free 
bromine has disappeared. The sodium hypobromite solution, if 
kept in a perfectly dark and cool place, may be preserved for a week 
or two. The reaction which takes place between the sodium hydrate 
and the bromine may be represented by the equation 

2NaOH + 2 Br = NaBr + NaOBr + H 2 0. 

Various forms of apparatus, termed areometers, have been sug- 
gested for the estimation of urea by this method. One which I 
have found very satisfactory is represented in Fig. 85. It consists 
essentially of a burette, C, with an ascending rubber tube attached 
to the reservoir B, which can be raised or lowered as required for 
the purpose of equalizing the pressure after collection of the gas. 
A descending tube leads to a wide-mouthed bottle, A, which con- 
tains the hypobromite solution. This is closed by a tightly fitting 
rubber stopper, to which a loop of platinum wire is attached carry- 
ing a little bucket made of glass or porcelain ; this can be swung 
from its support by inclining the bottle. 

Method. — The rubber stopper is removed from the bottle A, and 
water poured into B until the system BCA is filled to such an ex- 
tent that the water-level is visible in B above the point where the 
rubber tube is attached. About 25 to 30 c.c. of the hypobromite 
solution are placed in the bottle A, and 2 c.c. of urine in the 
bucket ; this is then attached to the wire loop. The stopper is now 



356 



THE TEHsE. 



carefully adjusted and the crater in I> and C brought to the 
level, when the first reading is taken. A is then inclined until the 
bucket drops into the liquid below. The nitrogen which is Haeir- 

ated collects in the 1 ■:_:-. —.- '. 



Pig. 85. 




a consequence the water mil - 
O and rises in I>. Afi 
to thirty minutes the pre* - 
in C is equalized by loureifflni^ JB 
until the water in both tubes 
is at the same level. Tbz 
ond reading is then take: i - 
difference between the two indi- 
cating the volume of nitrogen 
liberated from 2 c.c. of umnne atffc 
the temperature of the wafts n 
CB, which, as well as the baro- 
metric pressure, should be 
viously noted. 

As the volum-r 
greatly infiuenced by the 
perature, the barometric pre* 
and the tension of the aqauesuniffi 
vapor, it becomes ne> 
order that the results reached 
shall be comparable with illbgBBe 
obtained by other observe: - - 
reduce the volume of nit:- <gea 
actually noted to a certain stand- 
ard. This bas been placed 



~" 



The authors ureomexer. 



1 



C. and 760 merer.: 
pressure, in the : ';-: ■:•-. 
ure. This correction m m 
cording to the foUowiz r : 

in "which V represents the c 



teas 

-- 
ae- 



the volume act:. 



760.(1 — 0.00366./) 
volume of the gas in terms of c.c. 
served, B the barometric pressure in Hg mm .. __-":- : : :_t 
aqneous vapor at the temperature noted, t The volume : : tr:>ger: 
observed being thus corrected, the calculation of the carassqwaBdEnqgr 
amount of urea is based upon the following consideration: : : ~ 
the formula GO'S JI 4 it is apparent that 2 atoms of nitegigBii sore 
contained in 1 molecule of urea : in other words, that M - fey 

weight of nitrogen correspond to 60 parts by weight of urea. The 
equivalent of 1 gramme of urea is then found according 
equation : 60 : 28 : : 1 : x ; and x = 0.46666. The volume corre- 
sponding to 0.4666 gramme of dry nitrogen an md 70© 



CHEMISTRY OF THE URINE. 



357 



ETgmm. pressure is 372.7 c.c. It has been found, however, that 
onlv 354.3 c.e. of nitrogen are evolved from 1 gramme of urea at 
best when the hypobromite method is employed. Knowing that 
35 L3 c.c. of nitrogen correspond to 1 gramme of urea, the amount 
of urea to which the volume of nitrogen actually observed is refer- 
able would then be found according to the equation 

1 : 354.3 : ix : u\ and x =— r — , in which y denotes the number of 
J 354.3 J 

cubic centimeters of nitrogen evolved from 2 c.c. of urine, and x the 
corresponding amount of urea. In 
order to ascertain the percentage- 
amount of urea it is only necessary 
to multiply the figure just obtained 
by 50. 

Precautions : 1. The urine must be 
free from albumin. 2. It should con- 
ta i n only about 1 per cent, of urea — 
i. e., not more than 0.025 gramme in 
2 c.c. Whenever a greater amount 
is noted, therefore, the urine is diluted 
to the proper degree, due allowance 
being made in the calculation. 

In ordinary clinical work the 
barometric pressure, as well as the 
tension of the aqueous vapor, may 
be ignored, and in the accompany- 
ing tables the corresponding amount 
of urea may be directly read off at 
the temperatures 5°, 10°, 15°, 20°, 
25°, and 30° C. 

Of other forms of apparatus, the 
ureometers devised by Doremus, 
Green, Marshall, Huffner, and 
Squibb may be mentioned. 

The latest modification of Dore- 
mus' apparatus is Certainly most Doremus' ureometer. 

convenient, and can be highly rec- 
ommended. Its general construction is seen in Fig. 86. A small 
amount of urine is poured into B while the stopcock (G) is closed. 
This is then opened for a moment and again closed, so as to fill its 
lumen. The tube A is washed out with water and filled with the 
hypobromite solution. The tube B is filled with urine, and 1 c.c. 
(or less, if the urine is concentrated) is allowed to mix with the hypo- 
bromite solution in A. After all bubbles of gas have disappeared 
the reading is taken. The degrees marked upon the tube indicate 




358 



THE URINE. 



Urea. Table eor a Temperature of 5° C. 





1 


_L 


2 


_3_ 


4 


_5_ 


_6_ 


7 


A 


_9_ 




10 


10 


10 


10 


10 


10 


10 


10 


1 


1.32 


1.45 


1.58 


1.71 


1.85 


1 98 


2.11 


2.24 


2.37 


2.51 


2 


2.64 


2.77 


2.90 


3.03 


3.17 


3.30 


3.43 


3.56 


3.69 


3.83 


3 


3.96 


4.09 


4.22 


4.36 


4.49 


4.62 


4.75 


4.88 


5.02 


5.15 


4 


5.28 


5.41 


5.54 


5.63 


5.81 


5.94 


6.07 


6.20 


6.34 


6.47 


5 


6.60 


6 73 


6.87 


7.00 


7.13 


7.26 


7.39 


7.53 


7.66 


7.79 


6 


7.92 


S.05 


8.19 


5.32 


3.45 


8.58 


8.71 


8.85 


8.98 


r.n 


7 


9.24 


9.38 


9.51 


9.64 


9.77 


990 


10.04 


10.17 


10.30 


10.43 


8 


10.56 


10.70 


10.83 


10.96 


11.09 


11.22 


11.36 


11.49 


11.62 


11.75 


9 


11.89 


12.02 


12.15 


12.23 


12.41 


12.55 


12.68 


12.51 


12.94 


13.07 


10 


13.21 


13.34 


13.47 


13.60 


13.73 


13.87 


14.00 


14.13 


14.26 


14.39 


11 


14.53 


14.66 


14.79 


14.92 


15.06 


15.19 


15.32 


15.45 


15.53 


15.72 


12 


15.S5 


15.93 


16.11 


16.24 


16.38 


16.51 


16.64 


16.77 


16.90 


17.04 


13 


17.17 


17.30 


17.43 


17.57 


17.70 


17.83 


17.96 


18.09 


15.23 


18.36 


14 


18.49 


18.62 


18.75 


13.89 


19.02 


19.15 


19.23 


19.41 


19.55 


19.68 


15 


19.81 


19.94 


20.0S 


20.21 


20.34 


20.47 


20.60 


20.74 


20.S7 


21.00 


16 


21.13 


21.26 


31.40 


21.53 


21.66 


21.79 


21.92 


23.06 


22.19 


22.32 


17 


22.45 


23.59 


22.72 


22.85 


22.93 


23.11 


23.25 


23.3S 


23.51 


23.64 


18 


23.77 


23.91 


24.04 


24.17 


24.30 


24.43 


24.57 


24.70 


24.53 


24.96 


19 


25.10 


25.23 


25.36 


25.49 


25.62 


25.76 


25.89 


26.02 


26.15 


26.23 


20 


26.42 


26.55 


26.63 


26.81 


26.94 


27.03 


27.21 


27.34 


27.47 


27.60 


21 


27.74 


27.87 


23.00 


28 13 


28.27 


23.40 


28,55 


28.66 


2S."9 


28.93 


22 


29.06 


29.19 


29.32 


29.45 


29.59 


29.72 


29.85 


29.93 


30.11 


30 25 


23 


30.38 


30.51 


30.64 


30.78 


30.91 


31.04 


31.17 


31.30 


31.44 


31.57 


24 


31.70 


3183 


31.96 


32.10 


32.23 


32.36 


32.49 


32.62 


32.76 


32.89 


25 


33.02 


33.15 


33.29 


33.42 


33.55 


33.68 


33.81 


33.95 


34.03 


34.21 


26 


34.34 


34.47 


34.61 


34.74 


34.S7 


35.00 


35.13 


35.27 


35.40 


35.53 


27 


3-5.66 


35.S0 


35.93 


36.06 


36.19 


36.32 


36.46 


36 59 


36.72 


36.85 


28 


36.93 


37.12 


37.25 


37.33 


37.51 


37.64 


37.78 


37.91 


38.04 


38.17 


29 


38.31 


38.44 


38 57 


38.70 


38.S3 


3S.97 


39.10 


39.28 


39.36 


39.49 


30 


39.63 


39.76 


39.89 


40.02 


40.15 


40.29 


40.42 


40.55 


40.68 


40.81 



Urea. Table for a Temperature of 10° C. 





1 


JL 


2 


-A- 


4 


5 


6 




_a_ 


_9_ 






10 


10 


10 


10 


10 


10 


10 


10 


10 


1 


1.31 


1.43 


1.56 


1.69 


1.52 


1.95 


2.08 


2.21 


2.34 


2.47 


2 


2.60 


2.73 


2.86 


2.99 


3.12 


3.25 


3.38 


3.51 


3.64 


3.77 


3 


3.90 


4.03 


4.16 


4.29 


4.42 


4.55 


4.68 


4.81 


4.94 


5.07 


4 


5.20 


5.33 


5.46 


5.59 


5.72 


5.^5 


5.93 


6.11 


6.24 


6.37 


5 


6.50 


6.33 


6.76 


6.89 


7.02 


7.15 


7.23 


7.41 


7.54 


7.67 


6 


7.8 


7.93 


8.06 


8.19 


8.32 


8.45 


8.53 


8.71 


8.84 


8.97 


7 


9.10 


9.23 


9.36 


9.49 


9.62 


9.75 


9.88 


10.01 


10.14 


10.27 


8 


10.40 


10.53 


10.66 


10.79 


10.92 


11.05 


11.13 


11.31 


11.44 


11.57 


9 


11.71 


11.84 


11.97 


12.10 


12.23 


12.36 


12.49 


12.62 


12.75 


12.88 


10 


13.01 


13.14 


13.27 


13.40 


13.53 


13.66 


13.79 


13.92 


14.05 


14.18 


11 


14.30 


14.44 


14.57 


14.70 


14,53 


14.95 


15.09 


15.22 


15,35 


15.48 


12 


15.60 


15.74 


15.87 


16.00 


16.13 


16.26 


16.39 


16 52 


16.65 


16.73 


13 


16.91 


17.04 


17.17 


17.30 


17.43 


17.56 


17.69 


17.82 


17 95 


18.03 


14 


18.21 


18.34 


1*.47 


1^.60 


18.73 


18.86 


1S.99 


19.12 


19.25 


19.38 


15 


19.51 


19.64 


19.77 


19.90 


20.03 


20.16 


20.29 


20.42 


20.55 


20.68 


16 


20.81 


20.94 


21.07 


21.20 


21.33 


21.46 


21.59 


21.72 


21.85 


21.98 


17 


22.11 


22.24 


22.37 


22.50 


22.63 


22.76 


22.89 


23.02 


23.15 


23 28 


1- 


23.41 


23.54 


23.67 


23.80 


23.93 


24.06 


24.19 


24.32 


24.45 


24,55 


19 


24.72 


24.-5 


24 98 


25.11 


25.24 


25.37 


25.50 


25.63 


25.76 


25.89 


20 


26.02 


26.15 


26.23 


26.41 


26.54 


26.67 


26.80 


26.93 


27.06 


27.19 


21 


27.32 


27.45 


27.58 


27.71 


27.54 


27.97 


2S10 


28.23 


28.36 


28.49 


22 


28.62 


2^.75 




29.M1 


29.14 


29.27 


29.40 


29,53 


29.66 


29.79 


23 


29.92 


30.05 


30.18 


30.31 


30.44 


30.57 


:;0.70 


30.83 


30.96 


31.09 


24 


31.22 


31.35 


31.48 


31.61 


31.74 


31,57 


32.00 


32.13 


32.26 


32.39 


25 


32.52 


32.65 


32.78 


32.91 


33.04 


33.17 


33.30 


33.43 


33.56 


33.69 


26 


33.82 


33.95 


34.08 


34.21 


34.34 


34.47 


34.60 


34.73 


34.86 


34.99 


27 


35.12 


35.25 


35.38 


35.51 


35.64 


3^.77 


35.90 


36.03 


36.16 


36.29 


28 


36.42 


36,55 


36.68 


35.51 


36.94 


37.07 


37.20 


37.°,:! 


37.46 


37.59 


29 


37.73 


37.86 


37.99 


38.12 


38.25 


38.38 


38.51 


38.64 


35.77 


38.90 


30 


39.03 


39.16 


39.29 


39.42 


39.55 


39.68 


39,81 


39.94 


40.07 


40.20 



CHEMISTRY OF THE URINE. 



359 



Urea. Table for a Temperature of 15° C. 





1 


1 
1 " 


tV 


ft 


ft 


,";, 


ft 


ft 


ft 


ft 


l 


1.28 


1.41 


1.53 


1.66 


1.70 


1.92 


2.04 


2.17 


2.30 


2.43 


2 


2.56 


2.69 


2.81 


2.94 


3.07 


8.20 


3.33 


3.46 


3.58 


3.71 


3 


3.84 


3.97 


4.10 


4.22 


4.35 


4.48 


4.61 


4.74 


4.87 


4.99 


4 


5.12 


5.25 


5.88 


5.50 


5.63 


5.76 


5.89 


6.02 


6.14 


6.27 


6 


6.40 


6.53 


6.60 


6.79 


6.91 


7.04 


7.17 


7.30 


7.43 


7.55 


6 


7.68 


7.81 


7 91 


8.07 


8.19 


8.32 


8.45 


8.58 


8.71 


8.83 


7 


8.96 


9.09 


9.22 


9.35 


9.48 


9.60 


9.73 


9.86 


9.99 


10.12 


8 


10.24 


10.37 


10.50 


10.63 


10.76 


10.88 


11.01 


11.14 


11.27 


11.40 


9 


11.53 


11.65 


11.78 


11.91 


12.04 


12.17 


12.29 


12.42 


12.55 


12.68 


10 


12.81 


12.93 


13.06 


13.19 


13.32 


13.45 


13.57 


13.70 


13.83 


13.96 


11 


14.09 


1 4.22 


14.34 


14.47 


14.60 


14.73 


14.86 


14.98 


15,11 


15.24 


12 


15.37 


15.50 


15.62 


15.75 


15.88 


16.01 


16.14 


16.26 


16.39 


16.52 


13 


16.65 


16.78 


16.91 


17.03 


17.16 


17.29 


17.42 


17.55 


17.67 


17.80 


14 


17.93 


18.06 


18.19 


18.31 


18.44 


18.57 


18.70 


18.83 


18.95 


19.08 


15 


19.21 


19.34 


19.47 


19.60 


19.72 


19.85 


19.98 


20.11 


20.24 


20.36 


16 


20.49 


20.62 


2H.7.-. 


20.S8 


21.00 


21.13 


21.26 


21.39 


21.52 


21.64 


17 


21.77 


21.90 


22.03 


22.16 


22.29 


22.41 


22.54 


22.67 


22.80 


22.93 


18 


23.05 


23.18 


23.31 


23.44 


23.57 


23.69 


23.82 


23.95 


24.08 


24.21 


19 


24.34 


24.46 


24.59 


24.72 


24.85 


24.98 


25.10 


25.23 


25.36 


25.49 


20 


25.62 


25.74 


25.87 


26.00 


26.13 


26.26 


26.38 


26.51 


26.64 


26.77 


21 


26.90 


27.03 


27.15 


27.28 


27.41 


27.54 


27.67 


27 79 


27.92 


28.05 


22 


28.18 


28.31 


28.43 


28.56 


28.69 


28.S2 


28.95 


29.07 


29.20 


29.33 


23 


29.46 


29.59 


29.72 


29.84 


29.97 


30.10 


30.23 


30.36 


30.48 


30.61 


24 


30.74 


30.87 


31.00 


31.12 


31.25 


31.38 


31.51 


31.64 


31.76 


31.89 


25 


32.02 


32.15 


32.28 


32.41 


32.53 


32.66 


32.79 


32.92 


33.05 


33.17 


26 


33.30 


33.43 


33.56 


33.69 


33.81 


33.94 


34.07 


34.20 


34 33 


34.45 


27 


34.5S 


34.71 


34.84 


34.97 


35.10 


35.42 


35.35 


35.48 


35.61 


35.74 


•> 


35.86 


35.99 


36.12 


36.25 


36.38 


36.50 


36.63 


36.76 


36.89 


37.02 


29 


37.15 


37.27 


37.40 


37.53 


37.66 


37.79 


37.91 


38.04 


38.17 


38.30 


30 


38.43 


38.55 


38.68 


38.81 


38.94 


39.07 


39.12 


39.32 


39.45 


39.58 



Urea. Table for a Temperature of 20° C. 





1 


_1_ 


_2_ 


JL 


_4_ 


_5_ 


Ji_ 




JL 


_s_ 






10 


10 


10 


10 


10 


10 


10 


10 


10 


1 


1.26 


1.38 


1.51 


1.63 


1.76 


1.89 


2.01 


2.14 


2.26 


2.39 


2 


2 52 


2.64 


2.77 


2.90 


3.02 


3.16 


3.27 


3.40 


3.53 


3.65 


3 


3 " : 


3.91 


4.03 


4.16 


4.28 


4.41 


4.54 


4.66 


4.79 


4.91 


4 


5.04 


5.17 


5.29 


5.42 


5.54 


5.67 


5.80 


5.92 


6.05 


6.17 


5 


6.30 


6.43 


6.55 


6.68 


6.81 


6.93 


7.H6 


7.18 


7.31 


7.44 


6 


7.56 


7.69 


7.81 


7.94 


8.07 


8.19 


8.32 


8.44 


8.57 


8.70 


7 


8.82 


8.95 


9.08 


9.20 


9.33 


9.45 


9.58 


9.71 


9. S3 


9.96 


8 


10.08 


10.21 


10.34 


10.46 


10.59 


10.71 


10.84 


10.97 


11.09 


11.22 


9 


11.35 


11.47 


11.60 


11.72 


11.85 


11.98 


12.10 


12.23 


12.35 


12.48 


10 


12.61 


12.73 


12.86 


12.98 


13.11 


13.24 


13.36 


13.49 


13.61 


13.74 


11 


13.87 


13.99 


14.12 


14.25 


14.37 


14.50 


14.62 


14.75 


14.S8 


15.00 


12 


15.13 


15.25 


15.38 


15.51 


15.63 


15.76 


15.88 


16.01 


16.14 


16.26 


13 


16.39 


16.52 


16.64 


16.77 


16.89 


17.H2 


17.15 


17.27 


17.1U 


17.52 


14 


it. 65 


17.78 


17.90 


18.03 


18.15 


18.28 


18.41 


[8.53 


18.66 


18.78 


15 


18.91 


19.04 


19.16 


19.29 


19.42 


19.54 


19.67 


19.79 


19.92 


20 05 


16 


20.17 


20.30 


20.42 


20.55 


20.68 


20.80 


20.93 


21.05 


21.18 


21.31 


17 


21.43 


21.56 


21.69 


21.81 


21.94 


22.1.6 


22.19 


22.32 


22. 1 1 


22.57 


18 


22.69 


22.82 


22 95 


23.07 


23.2(1 


23.32 


23.45 


- 


2: 1.70 


23.83 


19 


23.96 


24.08 


24.21 


24.33 


24.46 




24.71 


24.84 


24.96 


25.09 


20 


25.22 


25.:: i 


25. 17 


25.59 


25.72 


25.85 


25.H7 


26.10 


26.22 


26.35 


21 


26.48 


26.60 




26.86 


26.98 


•J7.ll 


27.23 


27.36 


27.49 


27.61 


22 


27.74 




27.99 


28.12 


28.24 


28.37 


28.49 


■j. 62 


2S.75 




23 


29.00 


29.13 


29.25 


29.38 


29.50 




29.76 


29.88 


30.01 


30.13 


24 


20.26 


30.39 


30.51 


30.64 


30.76 




31.02 


31.14 


31.27 


31.39 


25 


31.52 


31.65 


31.77 


31.90 


32.03 


32.15 


32.28 


32 (0 


32.53 


32.66 


26 




32.91 




33.16 


33.29 


33.41 


33.54 




33.79 


33.92 


27 


34.04 


31.17 




34.42 


34.55 


34.67 


34.80 


34.93 


35.05 


35.18 


28 




35.43 


35.56 




35.81 


35.93 


36.06 


36.19 


36.31 


36. 1 1 


29 


I 36.57 


36 69 






37.07 


37.20 


37.32 


37.45 


37.57 


37.70 


30 


37.83 




38.08 


38.20 


38.33 


38.46 




38.71 







360 



THE URINE. 



Urea. Table for a Temperature of 25° C. 





• 


1 
10 


2 
10 


_3_ 
10 


_4_ 
10 


5 

10 


6 
10 


7 
10 


_8_ 
10 


A 


1 


1.24 


1.36 


1.49 


1.61 


1.73 


1.86 


1.98 


2.11 


2.23 


2.35 


2 


2.48 


2.60 


2.73 


2.85 


2.97 


3.10 


3.22 


3.35 


3.47 


3.59 


3 


3.72 


3.84 


3.97 


4.09 


4.22 


4.34 


4.46 


4.59 


4.71 


4.84 


4 


4.96 


5.08 


5.21 


5.33 


5.46 


5.58 


5.70 


5.83 


5.95 


6.08 


5 


6.20 


6.33 


6.45 


6.57 


6.70 


6.82 


6.95 


7.07 


7.19 


7.32 


6 


7.44 


7.57 


7.69 


7.81 


7.94 


8.06 


8.19 


8.31 


8.43 


8.50 


7 


8.68 


8.81 


8.93 


9.06 


9.18 


9.30 


9.43 


9.55 


9.68 


9.80 


8 


9.92 


10.05 


10.17 


10.30 


10.42 


10.54 


10.67 


10.79 


10.92 


10.04 


9 


11.17 


11.29 


11.41 


11.54 


11.66 


11.79 


11.91 


12.03 


12.16 


12.28 


10 


12.41 


12.53 


12.65 


12.78 


12.90 


13.03 


13.15 


13.27 


13.40 


13.52 


11 


13.65 


13.77 


13.89 


14.02 


14.14 


14.27 


14.39 


14.52 


14.64 


14.76 


12 


14.89 


15.01 


15.14 


15.26 


15.38 


15.51 


15.63 


15.76 


15.88 


16.00 


13 


16.13 


16.25 


16.38 


16.50 


16.63 


16.75 


16.87 


17.00 


17.12 


17.26 


14 


17.37 


17.49 


17.62 


17.74 


17.87 


17.99 


18.11 


18.24 


18.36 


18.49 


15 


18.61 


18.74 


18.86 


18.98 


19.11 


19.23 


19.36 


19.48 


19.60 


19.73 


16 


19.85 


19.98 


20.10 


20.22 


20.35 


20.47 


20.60 


20.72 


20.84 


20.97 


17 


21.09 


21.22 


21.34 


21.47 


21.59 


21.71 


21.84 


21.96 


22.09 


22.21 


18 


22.33 


22.46 


22.58 


22.71 


22.83 


22.95 


23.08 


23.20 


23.33 


23.45 


19 


23.58 


23.70 


23.82 


23.95 


24.07 


24.20 


24.32 


24.44 


24.57 


24.69 


20 


24.82 


24.94 


25.06 


25.19 


25.31 


25.44 


25.56 


25.68 


25.81 


25.93 


21 


26.06 


26.18 


26.30 


26.43 


26.55 


26.68 


26.80 


26.92 


27.05 


27.17 


22 


27.30 


27.42 


27.55 


27.67 


27.79 


27.92 


28.04 


28.17 


28.29 


28.41 


23 


28.54 


28.66 


28.79 


28.91 


29.04 


29.16 


29.28 


29.41 


29.53 


29.66 


24 


29.78 


29.90 


30.03 


30.15 


30.28 


30.40 


30.52 


30.65 


30.77 


30.90 


25 


31.02 


31.15 


31.27 


31.39 


31.52 


31.64 


31.77 


31.89 


32.01 


32.14 


26 


32.26 


32.39 


32.51 


32.63 


32.76 


32.88 


33.01 


33.13 


33.25 


33.38 


27 


33.50 


33.63 


33.75 


33.88 


34.00 


34.12 


34.25 


34.37 


34.50 


34.62 


28 


34.74 


34.87 


34.99 


35.12 


35.24 


35.36 


35.49 


35.61 


35.74 


35.86 


29 


35.99 


36.11 


36.23 


36.36 


36.48 


36.61 


36.73 


36.85 


36.98 


37.10 


30 


37.23 


37.35 


37.47 


37.60 


37.72 


37.85 


37.97 


38.09 


38.22 


38.24 



Urea. Tabee for a Temperature of 30° C. 





o 


JL 


2 


_3_ 


_4_ 


5 


J3_ 


7 


_8_ 


_9_ 






10 


10 


10 


10 


10 


10 


10 


10 


10 


1 


1.22 


1.34 


1.46 


1.58 


1.71 


1.83 


1.95 


2.07 


2.19 


2.32 


2 


2.44 


2.56 


2.68 


2.80 


2.93 


3.05 


3.17 


3.29 


3.41 


2.54 


3 


3.66 


3.78 


3.90 


4.03 


4.15 


4.77 


4.39 


4.51 


4.64 


4.76 


4 


4.88 


5.00 


5.12 


5.25 


5.37 


5.49 


5.61 


5.73 


5.86 


5.98 


5 


6.10 


6.22 


6.35 


6.47 


6.59 


6.71 


6.83 


6.96 


7.08 


7.20 


6 


7.32 


7.44 


7.57 


7.69 


7.81 


7.93 


8.05 


8.18 


8.30 


8.42 


7 


8.54 


8.67 


8.79 


8.91 


9.03 


9.15 


9.28 


9.40 


9.52 


9.64 


8 


9.76 


9.89 


10.01 


10.13 


10.25 


10.37 


10.50 


10.62 


10.74 


10.86 


9 


10.99 


11.11 


11.23 


11.35 


11.47 


11.60 


11.72 


11.84 


11.96 


12.08 


10 


12.21 


12.33 


12.45 


12.57 


12.69 


12.82 


12.94 


12.06 


13.18 


13.30 


11 


13.43 


13.55 


13.67 


13.79 


13.92 


14.04 


14.16 


14.28 


14.40 


14.53 


12 


14.65 


14.77 


14.89 


15.01 


15.14 


15.26 


15.38 


15.50 


15.62 


15.75 


13 


15.87 


15.99 


16.11 


16.24 


16.36 


16.48 


16.60 


16.72 


16.85 


16.97 


14 


17.09 


17.21 


17.33 


17.46 


17.58 


17.70 


17.82 


17.94 


18.07 


18.19 


15 


18.31 


18.43 


18.56 


18.68 


18.80 


18.92 


19.04 


19.17 


19.29 


19.41 


16 


19.53 


19.65 


19.78 


19.90 


20.02 


20.14 


20.26 


20.39 


20.51 


20.63 


17 


20.75 


20.88 


21.00 


21.12 


21.24 


21.36 


21.49 


21.61 


21.73 


21.85 


18 


21.97 


22.10 


22.22 


22.34 


22.46 


22.58 


22.71 


22.83 


22.95 


23.07 


19 


23.19 


23.32 


23.44 


23.56 


23.68 


23.81 


23.93 


24.05 


24.17 


24.29 


20 


24.42 


24.54 


24.66 


24.78 


24.90 


25.03 


25.15 


25.27 


25.39 


25.51 


21 


25.65 


25.76 


25.88 


26.00 


26.13 


20.25 


26.37 


26.49 


26.61 


26.74 


22 


26.86 


26.98 


27.10 


27.^2 


27.35 


27.47 


27.59 


27.71 


27.83 


27.96 


23 


28.08 


28.20 


28.32 


28'.45 


28.57 


28.69 


28.81 


28.93 


29.06 


29.18 


24 


29.30 


29.42 


29.54 


29.67 


29.79 


29.91 


30.03 


30.15 


30.28 


30.40 


25 


30.52 


30.64 


30.77 


30.89 


31.01 


31.13 


31.25 


31.38 


31.50 


31.62 


26 


31.74 


31.86 


31.99 


32.11 


32.23 


32.35 


32.47 


32.60 


32.72 


32.84 


27 


32.96 


33.09 


33.21 


33.33 


33.45 


33.57 


33.70 


33.82 


33.94 


34.06 


28 


34.18 


34.31 


34.43 


34.55 


34.67 


34.79 


34.92 


35.04 


35.16 


35.28 


29 


35.41 


35.53 


35.65 


35.77 


35.89 


36.02 


36.14 


36.26 


36.38 


36.50 


30 


36.63 


36.75 


36.87 


36.99 


37.11 


37.24 


37.36 


37.48 


37.60 


37.72 



CHEMISTRY OF THE URINE. 



361 



directly the number of grammes or grains of urea contained in the 
amount of urine employed. 1 

Green's apparatus (Fig. 87) consists of a tube, graduated in cubic 
centimeters, which is blown out at the bottom into a wider portion, and 
holds in all about 50 to 60c.c. The bulb is provided with a side-tube, 
"nto which a bent funnel-tube can be inserted for the purpose of equal- 
zing the pressure. The side-tube having been detached, the apparatus 
s filled with sodium hypobromite solution, when 2 c.c. of urine (di- 
luted if necessary) are introduced by means of a 
graduated and bent pipette. After all bubbles of Fig. 89. 

gas have disappeared the funnel-tube is inserted into 
the side-opening and filled with hypobromite solution 

Fig. 87. 





Green's ureometer. 



Marshall's ureometer. 



Huffner's ureometer. 



until the level in both tubes is the same. The volume is then 
noted, corrected, and the corresponding amount of urea calculated 
as described. 

Marshall's apparatus is a conveniently modified form of Green's, 
and is used in the same manner (Fig. 88). 

Hujt'iir,-'s apparatus is excellent (Fig. 89). It consists of a small 
bulb, A, of 5 c.c. capacity, which is separated from a larger bulb, 

C, holding about 100 c.c, by a well-oiled glass stopcock. The 
upper end of C is drawn out to such an extent that the eudiometer 

D, which is about 30 cm. long, 2 cm. wide, and divided into fifths 



1 Instead of employing the solution described on page •">•"."">, it is sufficient to fill the 
lonjrarm of the tube with a to per cent, solution of caustic soda, and to add 1 c.c. of 
bromine and a sufficient amount of water to fill the bend of the tube. 



362 



THE URINE. 



of a cubic centimeter, can be passed over it for a short distance. 
The bowl E, fitted over C by means of a cork, serves to hold a 
portion of the hypobromite solution. 

The exact capacity of A and of the lumen of the stopcock must 
be separately determined for each instrument. 

Method. — The bulb A and the lumen of the stopcock are filled 
with urine (which has been diluted, if necessary). The stopcock 
having been closed, C is washed out carefully with distilled water 
and filled with the hypobromite solution until the liquid in the dish 
stands several centimeters above the mouth of C. The eudiometer 
is next filled with the same solution, carefully submerged in the 
liquid contained in the dish, and adjusted over the mouth of C. 
The urine in A is then allowed to mix with the hypobromite solution 
very gradually, by opening the stopcock. After all bubbles of gas 
have disappeared the eudiometer is transferred to a cylinder filled 
with water and thoroughly immersed. After twenty to thirty 
minutes the level of the liquid in the tube and that of the outside 
water are equalized and the reading taken. The temperature of 
the water being likewise noted, the volume of the gas is corrected 
and the corresponding amount of urea calculated. 

Squibb's Method. — This method, like that of Doremus, may be 
highly recommended to the practitioner for its simplicity. The 
apparatus (Fig. 90) consists of two ordinary medicine-bottles, A and 



Fig. 90. 




Squibb's ureometer. 



B. In A the nitrogen is evolved. B is closed by a doubly perforated 
rubber stopper, a straight tube passing through the upper aperture 
and connecting with the bottle A. Another tube, bent downward 
and carrying a clamp, as seen in the figure, leads to a graduated 
cylinder, E. B contains a sufficient amount of water for the bent 
tube to dip into ; 25 to 30 c.c. of the hypobromite solution and a 



CHEMISTRY OF THE URINE. 363 

small tube containing 2 c.c. of urine (diluted if necessary, according 
to the specific gravity) are placed in A, the clamp at E being closed. 
The rubber stopper is now firmly inserted and E opened, when a 
few drops of water, which may be disregarded, will escape. The 
graduated cylinder is then placed beneath the outflow-tube and the 
bottle A inclined. The nitrogen collecting in B displaces its own 
volume oi' water, which flows out and is collected in E, whence the 
corresponding amount of urea may be calculated or read off from 
the accompanying tables (pages 358-360). 

It should be mentioned that sodium hypobromite liberates nitro- 
gen not only from urea, but also from the other nitrogenous con- 
stituents of the urine ; the error thus incurred, however, appears 
just to counterbalance the deficit in the amount of nitrogen obtained, 
and corresponds to 1 gramme of urea. 

If greater accuracy is required, the method recently suggested by 
Folin may be employed. 1 

Method of Folin. — This is based upon the following considera- 
tions : At a temperature of about 160° C. crystallized magnesium 
chloride, MgCl,.bH 2 0, boils in its water of crystallization. In such 
a solution urea is quantitatively decomposed into ammonia and 
carbon dioxide within one-half hour. If the process is carried out 
in acid solution, the ammonia can subsequently be distilled off after 
rendering the mixture alkaline, and is then titrated. The cor- 
responding amount of urea is ascertained by calculation. At the 
same time, however, the preformed ammonia is obtained, and it is 
hence necessary to eliminate this source of error by a separate 
estimation of this form. This is conveniently done according to 
the method which has likewise been suggested by Folin (see below). 

Method. — Three c.c. of urine are placed in an Erlenmeyer flask 
of 200 c.c. capacity, together with 20 grammes of magnesium 
chloride and 2 c.c. of concentrated hydrochloric acid. (The magne- 
sium chloride usually contains a small amount of ammonia, which 
must be separately determined.) The flask is closed with a per- 
forated stopper through which a straight glass tube passes, measur- 
ing 200 mm. in length, with a diameter of 10 mm. The mixture is 
now boiled until the drops flowing back through the tube produce 
a hissing sound on coming in contact with the solution. Alter this 
point has been reached, the boiling is continued more moderately for 
twenty-five to thirty minutes. The solution while still hot is care- 
fully diluted to about 500 c.c. — at first by allowing the water to flow 
drop by drop through the tube ; it is then transferred to a 1000 e.e. 
retort, treated with about 7 or 8 c.c. of a 20 per cent, solution of 
sodium hydrate, and the ammonia distilled off into a measured 
amount of a decinormal solution of sulphuric acid. The distillation 
maybe interrupted when about 350 c.c. have passed over (viz., alter 

1 O. Folin, Zeit. f. physiol. Cheni., vol. xxxii. p. 504. 



364 THE URINE. 

about sixty minutes). The distillate is boiled for a moment to 
remove any carbon dioxide which may be present in solution, and 
on cooling is titrated to determine the excess of acid. Each cubic 
centimeter of the decinormal ammonia present in the distillate cor- 
responds to 0.003 gramme, viz., to 0.1 per cent, of urea. 

From this result the amount of preformed ammonia and that 
present in the 20 grammes of magnesium chloride must be deducted. 

Estimation of Nitrogen. — For the purpose of estimating the total 
amount of nitrogen in the urine, the method of Kjeldahl or that of 
^Yill-Varrentrapp is most conveniently employed. 

KjeldaM's Method. 1 — Principle. — The organic matter of the urine 
is decomposed by means of sulphuric acid, when all the nitrogen 
which is not present in combination with oxygen is transformed into 
ammonia. After adding sodium hydrate in excess the ammonia is 
then distilled off and received in a known quantity of titrated acid, 
the excess being retitrated with sodium hydrate. In this manner 
the amount of ammonia and the corresponding quantity of nitrogen 
are ascertained, it being remembered that 17 grammes of ammonia 
correspond to 14 grammes of nitrogen. 

Reagents required : 

1. Gunning's mixture. This consists of 15 c.c. of concentrated 
sulphuric acid, 10 grammes of potassium sulphate, and 0.5 gramme 
of cupric sulphate. 

2. A solution of sodium hydrate containing 270 grammes in the 
liter (sp. gr. 1.243). 

3. Pulverized talcum or granulated zinc. 

4. A one-fourth normal solution of sulphuric acid. 

5. A one-fourth normal solution of sodium hydrate. 
Apparatus required (see Fig. 91) : This consists of a retort of 

about 750 c.c. capacity (A), which is connected with a Kjeldahl 
distilling tube (B), and through this with a Stadeler condenser (C). 
The ammonia is received in the nitrogen bulb at D. In addition a 
Kjeldahl digesting flask of 200 to 300 c.c. capacity is required. 

Method. — Five or 10 c.c. of urine are placed in the digesting 
flask and treated with Gunning's mixture. To this end, it is best 
to add the sulphuric acid and cupric sulphate first, to heat until sul- 
phuric acid vapors are given off in abundance, and then to add the 
potassium sulphate. The heating is continued until the solution 
becomes entirely clear and almost colorless, the flask being inclined 
at an angle of about 45 degrees. Vigorous ebullition should be 
avoided. 

Upon cooling, the contents of the flask are transferred to the re- 
tort with the aid of a little water, and slowly treated with a moder- 
ate excess of the sodium hydrate solution. As a general rule, 40 

1 J. Kjeldahl, " Neue Methode zur Bestiminung des Stickstofies in organischen 
Korpern,'" Zeit. f. analvt. Cheui.. 1883, vol. xxii. p. 366. 



ciihMisrin' of Tin: rniSE. 



365 



c.c. for each 5 c.c. of sulphuric acid arc sufficient. A little pulver- 
ized talcum or a few pieces of granulated zinc arc finally added; the 
retort is connected with the condenser, and the distillation begun. 
This is continued until about two-thirds of the solution have passed 
over. The distillate 1 is received in the nitrogen bulb, which should 
contain a carefully measured quantity of the one-fourth normal 
solution of sulphuric acid. As a general rule, 30 c.c. are sufficient. 
As soon as the distillation is completed the condenser is discon- 
nected, washed out with a small amount of distilled water, and the 
washings added to the distillate. After the addition of a few 



Fig. 91. 




Kjeldahl's nitrogen apparatus. 

drops of tincture of cochineal or dimethyl-amido-azo-benzol the 
excess of sulphuric acid is retitrated with the one-fourth normal 
solution of sodium hydrate, and the amount found deducted from 
the 30 c.c. used. The titration should be continued until every 
trace of yellow has disappeared and a pure rose color is obtained, 
or, in the case of the dimethyl-amido-azo-benzol, until the last trace 
of red has disappeared and the solution has turned yellow. The 
difference multiplied by 0.0035 will then indicate the amount of 
nitrogen present in the 5 or 10 c.c of urine. The corresponding 
amount of urea is found by multiplying this figure by 20. 



366 



THE UBINR 



As KjeldahTs method presupposes a thorough knowledge of 
chemical technique, it is well to make at least two parallel estima- 
tions in every ease. 

Will-Varreritrapp's Method i as modified by Seegen-Schneider J — 
Principle. — If nitrogenous organic material is heated in intimate 
contact with soda-lime, all the nitrogen is given on in the form i >f 
ammonia, which is received in a known quantity of acid : the excess, 
nut used in the neutralization of the ammonia, is then determined 
by titration with a solution of sodium hydrate of known strength. 

Fig. 92. 




^ ^: " ^- 



Apparatus f:r the ietert^itiat::-:: ::' nitroeen. 

The amount held by the ammonia is thus ascertained, and from it 
the corresponding amount of nitrogen, it being remembered that 17 
grammes of ammonia correspond to 14 grammes of nitrogen. 
Reagents required : 

1. A quantity of thoroughly fused soda-lime, which, while still 
hot, should be placed in a well-stoppered bottle, where it may be 
kept ready for use for a long time. 

2. A normal solution of sulphuric acid. 

3. A normal solution of sodium hydrate. 

Apparatus required : As is apparent from the accompanying (dia- 
gram Fig. '.. :, 2 . the apparatus consists of a Kjeldahl digesting flask, 
A y of about 100 c.c. capacity, and provide! with a neck 10 to 12 cm. 
long : this is placed in a copper crucet. B. and imbedded in sand. 
1 Will-Varrentrapp. see Leube-Salkowski. Die Lehre vom Hani. 



CHEMISTRY OF THE URINE. 367 

The crocet is placed upon a pipe-stem triangle over the flame. The 
neck of the flask is surrounded by a hood of copper or tin plate, (\ 
moulded to the flask and reaching not higher than 1.5 cm. below 
the rubber stopper. The latter is doubly perforated, a tube, e, 
drawn out to a point and closed at the free end, passing through 
one aperture and extending about half-way down the flask, while 
the second passes through the other opening. This second tube, 
i ■. is connected by means of a short piece of rubber tubing, upon 
which a clamp is placed, with a Will-Varrentrapp apparatus. The 
latter is connected by rubber tubing, upon which a clamp is likewise 
placed, with an aspirating-bottle filled with water and provided with 
a siphon tube. 

Method. — Ten c.c. of the normal sulphuric acid solution are 
placed in the AVill-Varrentrapp apparatus, together with a few 
cubic centimeters of a 1 per cent, alcoholic solution of phenol- 
phthalein. A layer of sand about 1 cm. in height is placed in the 
crucet, the clamp a closed, and the flask filled to about one-half its 
height with the soda-lime, when the hood is adjusted and 5 c.c. of 
urine are allowed to flow upon the soda. The rubber stopper is 
quickly adjusted, the rubber tube having been previously connected 
with the Will-Yarrentrapp apparatus. The clamp a is now opened, 
the crucet filled with sand, and the heating begun. This is at first 
done carefully with a small flame, but increased gradually until a 
full heat is applied. This is continued for one-half to three-quarters 
of an hour. "When drops of moisture are no longer visible in the 
tube c, or when the evolution of gas has entirely ceased, the rubber 
tube of the aspirating-bottle d is slipped on to the Will-Varrentrapp 
apparatus, the clamp b slightly opened, the tip of e broken off, and 
air allowed to pass slowly through the entire system for a quarter 
of an hour, when the flame is extinguished. The TTill-Varrentrapp 
apparatus is then detached and its contents titrated with the normal 
solution of sodium hydrate. 

The number of cubic centimeters of the sodium hydrate solution 
employed is deducted from 10 (the number of cubic centimeters of 
the normal sulphuric acid solution, 1 c.c. of the latter being equiva- 
lent to 1 c.c. of the former), the difference giving the number of 
cubic centimeters of the normal sulphuric acid solution neutralized 
by the ammonia evolved from 5 c.c. of urine. This number multi- 
plied by 20 will then represent the number of cubic centimeters 
required to neutralize the ammonia contained in 100 c.c. of urine. 
As 1000 c.c. of the normal solution of sulphuric acid correspond to 
17 grammes of ammonia, or 14 grammes of nitrogen, the number of 
cubic centimeters of the sulphuric acid solution corresponding to 
1<>() e.c. of urine will be found from the equation : 1000 : 1 4 ::./:// ; 
and y = 0.01 4. r, in which x represents the number of cubic centi- 
meters required to neutralize the amount of ammonia evolved from 



368 THE URINE. 

100 c.c. of urine, and y the corresponding amount of nitrogen — i. e., 
the percentage of nitrogen. 

If the nitrogen is to be calculated in terms of urea, this is done 
according to the equation : 1000 : 30 ( = 14N) : : x : y ; and y = 
0.03 x = percentage of urea, in which x represents, as above, the 
number of cubic centimeters of sulphuric acid neutralized by the 
ammonia, viz., nitrogen, contained in 100 c.c. of urine, and y the 
urea corresponding to this amount. 

Ammonia. 

Every urine contains a small amount of ammonia, which normally 
varies but little, and corresponds to from 4.1 to 4.64 per cent, of the 
total amount of nitrogen, viz., to about 0.7 gramme in the twenty- 
four hours. It is present in combination with the various acids of 
the urine, and in all likelihood represents a small amount of the 
ammonia which has not been transformed into urea, but has been 
utilized to saturate the affinities of a slight excess of acid, formed 
during the nitrogenous metabolism of the body, over the available 
fixed alkalies. In this manner indeed the body is capable of guard- 
ing against the appearance of free acid in the blood, and it is for 
this reason, as I have already pointed out, that free acid cannot 
occur in the urine. This safeguard, however, does not exist in 
the herbivorous animals, in which the fixed alkali only is apparently 
available for the neutralization of acids, and we consequently find 
that whereas in dogs, for example, an acid intoxication occurs only 
after the administration of very large quantities of acid, the herbivora 
rapidly succumb after the ingestion of comparatively small amounts. 

In man an increased elimination of ammonia is observed when- 
ever an increased formation of acids occurs, or whenever a sufficient 
supply of oxygen is not available. In the latter case, no doubt, 
the increased elimination is owing to the fact that in consequence 
of the deficient supply of oxygen the synthetic formation of urea 
from ammonium lactate is impeded in the liver. As this organ, 
moreover, is the principal seat of the synthesis of urea, we can 
readily understand that extensive parenchymatous degeneration, 
as in acute yellow atrophy, in phosphorus poisoning, etc., will lead 
to an increased elimination of ammonia. 

In any event, the relative increase of the ammonia is the 
essential factor, while variations in its absolute quantity are of 
secondary importance. Some of the results which have been 
obtained in various diseases are given in the following table : 

Per cent. 

Normal values 4.10- 4.64 

Febrile diseases 5.72- 6.70 

Carcinoma of the liver 6.40-24.50 

Liver abscess (actinomycosis) 10.60 

Circulatory dyspnoea 13.10-32.20 

Respiratory dyspnoea 6.60-14.30 



CHEMISTRY OF THE URINE. 



369 



Abnormally high absolute values are tjuitc constantly observed in 
diabetes, in which an elimination of from 4 to 5 grammes may be 
regarded as common. In one instance 5.94 grammes were excreted 
in twenty-four hours. 

Very curiously, diminished elimination of ammonia is observed 
in many cases of nephritis so long as symptoms of venous stasis 
do not exist. 

In a case of pernicious anaemia relative amounts, varying between 
3.3 and 5.6 per cent., were obtained during the days immediately 
preceding death. 

Quantitative Estimation. — Schlosing's Method. — Principle. — A 
carefully measured amount of urine is treated with milk of lime 
and placed under a bell, together with a vessel containing a known 

Fig. 93. 




Desiccator. 



amount of a normal solution of sulphuric acid. In the course of 
time the ammonia is liberated and absorbed by the acid. This is 
then titrated, and the deficit expressed in terms of ammonia. 

Method. — Twenty-five c.c. of perfectly fresh, filtered urine are 
placed in a flat dish, upon the plate of a desiccator, as shown in 
Fig. 93. Above this is a smaller dish containing 10 c.c. of a nor- 
mal solution of sulphuric acid. The urine is treated with 10 c.c. 
of milk of lime, the bell is carefully adjusted after lubrication 
with tallow, and the apparatus allowed to stand for at least three 
or four days. The excess of acid remaining is then titrated with a 
one-fourth normal solution of sodium hydrate, using as an indicator 
a few drops of a saturated aqueous solution of methyl-orange until 
the red color has turned to yellow. To neutralize the 10 c.c. of the 
acid, 40 c.c. of the one-fourth normal solution are required. The 
difference is referable to the partial neutralization by the ammonia, 



370 THE URINE. 

and is expressed in milligrammes. One c.c. of the one-fonrth 
normal solution corresponds to 4.25 mgrms. of ammonia. 

Precautions : 1. In every case the urine must be perfectly fresh. 
Decomposition is best guarded against during its collection by adding 
about 10 to 20 c.c. of chloroform to the portion first voided. 

2. Urines which are undergoing ammoniacal decomposition should 
not be utilized for examination. 

3. Concentrated or albuminous urines must be kept under the 
bell for from five to eight days, new portions of acid being used 
when in doubt as to the complete liberation of the ammonia. 

Owing to a slight deposition of moisture on the inner surface of 
the bell and a consequent retention of traces of ammonia in this 
form, the resulting figures are too low. The error thus incurred, 
however, is insignificant. 

More satisfactory than this older method is the following, which 
has recently been suggested by Folin : 

Folin's Method. — Ten c.c. of urine are diluted to about 450 c.c, 
treated with a small amount of burnt magnesia (0.5 gramme), and 
boiled for forty-five minutes, the distillate being received in decinor- 
mal sulphuric acid. The ammonia is then determined by titration 
as above. As a small amount of urea, however, is decomposed 
during the prolonged ebullition, it is necessary to ascertain separately 
the quantity of ammonia which is referable to this source. To this 
end, the retort is opened at the expiration of forty-five minutes, 
and an amount of water added which is approximately equivalent 
to that of the distillate. The distillation is then continued for 
another period of forty-five minutes ; the distillate is received in 
decinormal sulphuric acid, and the ammonia referable to decomposi- 
tion of the urea estimated as before. The difference between the two 
results indicates the amount of preformed ammonia that was origi- 
nally present. 

Literatuke. — Hallervorden, Arch. f. exper. Path., vol. xii. p. 237. Stadelmann, 
Deutsch. mecl. Woch., 1889, p. 942. Michaelis, Ibid., 1900, p. 276. O. Folin, Zeit. f. 
physiol. Chem., vol. xxxii. p. 575. 

Uric Acid. 

According to our present views, uric acid, in man, is not formed 
during the decomposition of all albuminous substances, as was for- 
merly supposed, but constitutes a specific product of decomposition 
of one class of albumins only, namely, the nucleins. 1 It appears, 
moreover, that the mother-substance of uric acid is confined to the 
nuclear nucleins, viz., to those containing a nucleinic acid radicle ; 
while the paranucleins, in which this is lacking, are without effect 
upon the elimination of uric acid. According to Kossel, 2 four differ- 

1 C. E. Simon, Physiological Chemistry, Lea Bros. & Co.. 1901. 

2 A. Kossel u. A. Neumann, " Ueber Nukleinsiiure u. Thymiusaure," Zeit. f. 
physiol. Chem., vol. xxii. p. 74. 



CHEMISTRY OF Till-: URINE. 371 

ent forms of aucleinic arid exist, viz., adenylic acid, guanylic acid, 
sarcylic acid, and xanthylic acid, and the suppositioD is that each of 
these contains one base, viz., adenin, guanin, sarcin or hvpoxanthin, 
and xanthin. These basic substances are collectively spoken of as 
the xanthin, altavur, or purin bases. According to Emil Fischer, 1 
they arc derived from a hypothetical compound which he terms purin, 
and which he snpposes to be constituted as shown in the formula 

(6) 
(1)N — — C H 

I I (7) 
(2)HC (5)C NH X 

II II >H(8). 
(3)N C N^ 

U) (9) 

By substituting the group XH 2 for the H atom at 6, adenin thus 
results, and is hence also spoken of as 6-aminopurin : 



N C.NH, 

-NH\ 

CH. 



HC C NH 



N 



N ^ 



Hvpoxanthin, according to this conception, would be 6-oxypurin ; 
xanthin 2, 6-dioxypurin, and guanin 2-amino-6-oxypurin, as shown 
by the structural formulae : 

HN CO HN CO 

HC C NH\ CO C NHs 

II II ^ch. I ii Vjh. 

N C N^ HN C N^ 

Hvpoxanthin. Xanthin. 

NH CO 

I I 

HN=C C NH X 

I II ^>CH. 

HN C N^ 

Guanin. 

From the structural formula of purin it is also apparent that still 
other derivatives of this substance may exist, and as a matter of 
fact others are known, viz., mono-methvlxanthin or heteroxanthin, 
di-methvlxanthin or paraxanthin, tri-methylxanthin, the isomeric 
compounds of paraxanthin, viz., theophyllin and theobromin, and 
others. Their relation to xanthin is shown in the formulae : 

HN CO UN CO 

II II 

CO C Nil CO C N.CH, X 

I II ^CH. | ^^ CH - 

HN C N^ UN C N^=^ 

Xanthin. Heteroxanthin. 

1 E. Fischer, Ber. d. Deutsch. chem. Ges., 1897, vol. xxx. p. 549. 



372 THE EEISE. 

CH^N 




_^CH. 
-C K= 

Paraxau thin. 



CH:.>- 





X.CH 3X 



^m- 



Two of these bodies, namely, heteroxanthin and paraxanthin, 
have also been found in urine. 

From these basic substances, then, which are found in the nucle- 
inic acid radicle of the nuclear nucleins. uric acid is supposedly 
derived, and there are numerous facts which go to show that this 
supposition is in all likelih- x>rrect, It will thus be observed 
that structurally uric acid is intimately related to the bodies in ques- 
tion, and, like these, contains the purin radicle : 

H>* CO 

I 1 

CO C NH 

! II >o. 

H>~ C >"H 

Uric acid. 

It may hence be regarded as 2, 6, v tri-oxypurin. Uric acid and 
xanthin-bases. moreover, qualitatively, all yield the same decom- 
position-products when treated with filming hydrochloric acid or 

hvdriotic acid under high pressure ; only the quantitative relations 
vary, as shown in the equations : 

<ML> ; - ; H-=^H : - Cv : — CH : .>~H/;OOH— CH.COOH 
Adenin. Glycoc V. I rroic acid. 

( -Hyj' - :hx» = 3VK, - co : - ch ; .:s~h ; .cooh - lih.cooh. 

Hypoxanthin. 

sHjN^ l - m,0 = 4>~H : - 2CO : - CH-.XH COOH - H.COOH. 
Guanin. 

' ; Hy- - ::-:_ o = 3xh ; - 2C0, - ch. : .nh : .cooh - h.cooh. 

Xanthin. 

H 4 H 4 3 - cH : o = 3XH £ - SCO. - CH : .>~H : .C<: OH. 
Uric acid. 

In accordance with this supposed rigin of uric acid we find an 
increased elimination in the urine following the ingestion of all sub- 
stances which contain purin bases either as such or in the form of 
nuclear nucleins. At the same time it must be remembered that 
uric acid may also result from the nucleins of the body-tissues : and 
we find, as a matter of fact, that during starvation uric acid does 



CHEMISTRY OF THE URINE. 373 

not disappear from the urine. The principal source of the uric acid 
under such conditions are the nueleins of the leucocytes ; and accord- 
ing to Horbaczewski ] and others, this source is indeed more impor- 
tant than the nueleins of the i'ood. According to his idea, the latter 
call forth an increased elimination of uric acid in only an indirect 
manner — /. e., by stimulating more strongly than other food-stuffs 
the cell-formation and cell-destruction of the body. However this 
may be, there can be no doubt that the amount of uric acid elimi- 
nated in the urine depends, in the first instance, upon the amount of 
nueleins or purin bases as such which are ingested, and upon the 
degree of nuclear destruction which takes place in the body. Other 
factors, however, also enter into consideration. AVe thus know that 
the body is capable of transforming a certain amount of uric acid 
into urea. This fact was pointed out long ago by Frerichs and 
Wohler, and has recently again been confirmed. It was found that 
after the ingestion of large amounts of nueleins only a certain por- 
tion of the nuclear nitrogen is eliminated as uric acid, and that this 
amount is extremely variable. Whether individual peculiarities 
have any part in determining this amount is unknown, but is not 
improbable. Oxidation on the part of the body-tissues must also 
be taken into consideration, and it unquestionably varies not only 
in different people, but also in the same individual at different times. 
Then again there is evidence to show that under certain conditions 
uric acid may be formed synthetically in the body. That this is the 
usual mode of formation in birds and reptiles has been conclusively 
shown by Minkowski, 2 who found that after extirpation of the liver 
in geese the greater portion of the urinary nitrogen was eliminated 
in the form of ammonia in combination with lactic acid. In the 
human being very little uric acid is in all likelihood formed in this 
manner under normal conditions, but the possibility of its occur- 
rence, in disease more particularly, should not be overlooked. As 
uric acid, moreover, may in part at least be eliminated in the 
feces, it is clear that the amount which appears in the urine cannot 
be regarded as an accurate index of the degree of nuclear destruc- 
tion or of the amount which is formed in the body-tissues. That 
retention of uric acid can further occur in the body, which may or 
may not be followed by increased elimination, is likewise undoubted. 

According to our present knowledge, uric acid is formed in all the 
organs of the body, including the bone-marrow, the muscles, the 
spleen, the liver, the kidneys, etc. Under pathological conditions it 
may also originate in the joints and tendons. 

Under norma] conditions the daily elimination of uric acid varies 
between 0.2 and 1.5 grammes, thus constituting ^ to yl-^ part of 

1 J. Horbaczewski, " Beitrage zur Kenntniss <1< ar Bildnng von Hamsaure," etc., 
Monatshefte far Chem., 1891, vol. xii. i>. 221 : and Wien. Sitznngsber., vol. <•. 

2 Minkowski, " Debet den EHnfluss d. Leberextirpation aut* den Stoffwechsel,*' 
Arcb. f. exper. Patb. u. Pharmakol., 1886, vol. xxi. p. 41. 



374 THE URINE. 

the total urinary nitrogen. It is largely influenced by the character 
of the diet, the amount of exercise taken, the general health of the 
individual, etc. After the ingestion of large amounts of food rich 
in nuclear nucleins, such as thymus gland, liver, kidneys, and brain, 
a corresponding increase in the amount of uric acid is observed. 
Generally speaking, animal food causes a greater elimination of uric 
acid than vegetable food, and it is supposed that this diiFerence is 
essentially due to the presence of the extractives of the meat. 1 Of 
special interest is the increase in the elimination of uric acid which 
is observed five hours after the ingestion of a full meal. This in- 
crease, according to Horbaczewski, 2 is associated with the disappear- 
ance of the digestive leucocytosis and consequent leucolysis. 

Some observers have attached much importance to the relation 
existing between the elimination of uric acid and urea, and are in- 
clined to assume the existence of a special uric acid diathesis when 
this relation continuously exceeds the usual standard of 1 : 50 or 
1 : 60. This question is, however, an extremely intricate one, and 
we are scarcely in a position at the present time to speak definitely 
of the significance of such variations. On the one hand, there can 
be no doubt that an unusually high uric acid coefficient may be met 
with in individuals who are apparently in good health, while in others, 
in whom larger amounts of uric acid are eliminated than are usual, 
normal or even subnormal values may be found. The entire ques- 
tion of the uric acid diathesis is in a chaotic condition, and it would 
perhaps be well to speak of such a diathesis only when a distinct 
absolute increase is continuously observed. That numerous symptoms 
of a neurasthenic type are often seen when the uric acid coefficient 
is increased, is a matter of daily observation, but it would be pre- 
mature to regard this symptom as a causative factor of the disease 
in question. 3 Even in gout it can scarcely be said that uric acid has 
been proved the materia peccans, and our knowledge concerning the 
etiology of the disease is still as obscure as when Garrod i showed 
that an accumulation of uric acid occurred in the blood of such pa- 
tients. Hitherto it has been supposed that the deposition of urates 
in the joints and periosteum of gouty patients is referable to a 
diminished alkalinity of the blood, and that acute paroxysms result 
whenever an increase in its alkalinity occurrs, leading to a resorp- 
tion of the urates previously deposited and a consequent flooding of 
the system with the material in question. As a matter of fact, a 

1 A. Hermann. " Abhangigkeit der Harnsaureausscheidung von Nahrungs- und Ge- 
nussmitteln.'' Deutsch. Arch. f. klin. Med., 18SS. vol. xliii. p. 273. See also W. Camerer, 
Zeit. f. Biol., X. F., 1596, vol. xv. p. 140. 

2 Horbaczewski. Harnsaureausscheidung u. Leucocytose. Sitzungsber. d. Wiener 
Akad. d. Wissensch., 1891, Abth. 3. See also Lowit. Studien z. Physiol, u. Path. d. 
Blutes, 1892. W. Kuhnau, " Das Verhaltniss d. Harnsaureausscheidung zur Leuco- 
cytose.'' Zeit. f. klin. Med., vol. xxviii. p. 534. P. F. Eichter, " Ueber Harnsaure- 
ausscheidung und Leucocvtose.*' Ibid., vol. xxvii. p. 290. 

3 C. E. Simon. Am. Jour. Med. Sci.. 1599. p. 139 . and X. Y. Med. Jour., 1S95, p. 330. 

4 A. B. Garrod, On the Nature and Treatment of Gout, 1847. 



CHEMISTRY OF THE URINE. 375 

considerable diminution in its excretion is observed immediately 
preceding the attack, while during the paroxysm and immediately 
following it a corresponding increase is noted. Numerous investi- 
gations, however, have shown that distinct changes in the alkalinity 
of the blood do not occur in gout, and that an increase in the amount 
of uric acid in the blood is not only observed in this disease, but in 
other diseases as well which are not associated with gouty symptoms. 
The conclusion is hence justifiable that the presence of uric acid in 
the blood per se cannot be offered as an explanation of the occur- 
rence of a gouty attack. 1 

The greatest increase in the elimination of uric acid is observed 
in leukaemia, in which amounts of 5 grammes and even more may 
be observed in the twenty-four hours. That the increased elimina- 
tion in this disease is referable to the enormous increase in the 
number of the leucocytes and consequent leucolysis can scarcely be 
doubted. In other diseases which are associated with a high grade 
of leucocytosis, and especially those in which the disease terminates 
by crisis or hastened lysis, such as erysipelas and pneumonia, a con- 
siderable increase is likewise observed, and is referable to the same 
origin. This increase is especially marked immediately after crisis 
has occurred, but it not infrequently precedes this by several hours. 
In the other febrile diseases an absolute increase is less marked and 
inconstant. 

In diabetes a diminished amount of uric acid is usually found. 
Cases may be seen, however, in which, associated with a diminution 
or an entire disappearance of the sugar, a most marked increase 
occurs, amounting in some cases to 3 grammes in the twenty-four 
hours. To this condition the term diabetes alternans has been 
applied. 

In acute articular rheumatism an increased elimination is observed 
so long as the temperature remains high, while with approaching 
convalescence the amount returns to normal, and may even fall 
below normal. In chronic rheumatism, on the other hand, no con- 
stant relations have been observed. 

In the ordinary forms of anaemia and chlorosis the amount of 
uric acid is quite constantly diminished, as also in chronic inter- 
stitial nephritis, chronic lead poisoning, progressive muscular atro- 
phy, and pseudohypertrophic paralysis. 

Properties of Uric Acid. — The close relation existing between 
uric acid and the xanthin-bases has been already considered. By 
oxidation uric acid is transformed into urea or into substituted ureas, 
such as allantoin and alloxan, which latter in turn is closely related 
to parabanic acid or oxalyl-urea and barbituric acid or malonyl-urea. 

1 B. Laquor. T'ober die Aussrlifidun^sverlialtnisso der Alloxurkorper. Bergmann, 
1896. (Full literature.) C. von Xoorden, Lehrbuch d. Pathologic d. Stoflwechsels, 
Berlin, 1893. W. Ebstein, " Die Xatur u. Behandlung der Gicht," Verhandl. d. VIII. 
Congr. f. inn. Med., 1889, p. 133. 



376 



THE URINE. 



C 5 H 4 N 4 0, 

Uric acid. 



O 



H a O 



C 4 H 2 N 2 4 

Alloxan. 



C0<r NH 2 

Urea. 



C 5 H 4 N 4 3 + H 2 + O 
Uric acid. 



cmo, + co s . 

Allantoin. 



Pure uric acid forms a white crystalline powder which is almost 
insoluble in cold water (1 : 40,000), with difficulty soluble in boiling 
water (1 : 1800), and insoluble in alcohol and ether. In concentrated 
sulphuric acid*it dissolves with ease, but is precipitated upon dilu- 
tion with water. In aqueous solutions of the alkaline carbonates 
and hydrates it dissolves, with the formation of neutral or acid salts, 
as represented by the equations : 

C 5 H 4 N 4 3 + Na 2 C0 3 = C 5 H 3 NaN 4 3 + NaHC0 3 . 
C 5 H 4 N 4 O a + 2Na 2 C0 3 = C 5 ET 2 Na 2 N 4 3 + 2NaHC0 3 . 

In freshly voided urine uric acid is said to occur as a quadriurate, 
viz., as a compound in which one molecule of sodium is in combina- 
tion with two molecules of uric acid. The quadriurate, however, is 
readily decomposed with the formation of uric acid and acid urates 



@<L*^ 




(biurates). Its solubility in the urine depends upon the amount of 
water present, the reaction, aud the presence of inorganic salts. 
When acid sodium phosphate preponderates the biurate is precipi- 
tated, while free uric acid is thrown down when disodic phosphate 
only is present, and along with this still other acid compounds which 
are most likely of organic nature. Neutral urates cannot occur in 
the urine. The basic substances which may occur in the urine in 
combination with uric acid are sodium, potassium, ammonium, and 
possibly also calcium and magnesium. These salts may be decom- 



CHEMISTRY OF THE URINE. 377 

posed by the addition of a sufficiently large quantity of a stronger 

acid, such as hydrochloric acid, when uric acid is set free. The acid 
salts arc soluble with great difficulty, and are hence precipitated 
whenever the urine is markedly acid or concentrated, and also when 
it is exposed to a low temperature. This holds good especially for 
the acid ammonium compound, and upon this fact Hopkins' quan- 
titative estimation of uric acid is based. 

Pure uric acid crystallizes in transparent, colorless, rhombic 
plates, while that which usually separates from the urine is of a 
reddish-brown color and may assume a great variety of forms (Fig. 
94). Of these, the so-called whetstone-form is the most character- 
istic (see Sediments). Colorless rhombic platelets may, however, 
also be seen. 

Of the compounds which uric acid forms w r itb the heavy metals, 
the silver salt is especially important. AVhen a solution of uric acid 
in ammonia is treated with an ammoniacal solution of silver nitrate 
(see below) the solution remains clear ; but if calcium chloride, 
sodium chloride, or magnesia mixture is then added, a precipitate 
forms, which contains the uric acid in combination with silver. 

Tests for Uric Acid. — 1. Murexid Test. — A few crystals are dis- 
solved by means of a few drops of concentrated nitric acid, with the 
application of heat, upon a porcelain plate, such as the cover of a 
crucible. The nitric acid is then carefully evaporated, when a yel- 
lowish-red spot will remain. Upon cooling, a drop of ammonia is 
placed upon this spot, when in the presence of uric acid a beautiful 
purplish-red color develops, owing to the formation of ammonium 
purpurate (murexid). If now 7 a drop of sodium hydrate solution is 
added, the color changes to a reddish blue, which disappears upon 
heating ; the reaction thus diifers from the somewhat similar xanthin 
reaction. 

2. Copper Test. — A few crystals are dissolved in sodium hydrate 
solution and treated with a few drops of Fehling's solution. Upon 
the application of heat white copper urate separates out, while red 
cuprous oxide appears if a relatively large amount of cupric sulphate 
is present — a point to be remembered in testing for sugar. The 
reduction of Fehling's solution is due to the formation of allantoin. 

3. When treated with -odium hypobromite solution uric acid gives 
up about 47 per cent, of its nitrogen. 

Quantitative Estimation of Uric Acid. — Hopkins' Method. — 
This method is now commonly used in the clinical laboratory, 
and is to be preferred to the more complicated procedures hitherto 
employed. Tt is much simpler and equally as accurate as the older 
methods of* Ludwig-Salkowski and of Haycraft. Various modi- 
fications of the original method have been suggested. 

Principle. — The method is based upon the complete precipitation 
of uric acid by ammonium salts, and the possibility of accurately 



378 THE URINE. 

titrating the uric acid with potassium permanganate in the presence 
of sulphuric acid. 

Folin's Modification of Hopkins' Method. 1 — To precipitate the uric 
acid, and also to remove the small amount of mucoid substance 
which is found in every urine, the following reagent is employed : 
500 grammes of ammonium sulphate and 5 grammes of uranium 
acetate are dissolved in 650 c.c. of water, to which solution 60 c.c. of 
a 10 per cent, solution of acetic acid are further added. The resulting 
solution measures about 1000 c.c. Seventy-five c.c. of the reagent are 
added to 300 c.c. of urine in a flask holding 500 c.c. After standing 
for five minutes the mixture is filtered through two folded filters, and 
thus freed from the mucoid body, which is carried down with the 
uranium phosphate in acid solution. The filtrate is divided into two 
portions of 125 c.c. each, which are placed in beakers and treated 
with 5 c.c. of concentrated ammonia. After stirring a little the solu- 
tions are set aside until the next day. The supernatant fluid is then 
carefully poured off through a filter (Schleicher and Schull, No. 597) ; 
the precipitated ammonium urate is collected with the aid of a small 
amount of a 10 per cent, solution of ammonium sulphate and washed 
with the same reagent. Traces of chlorides do not interfere with 
the subsequent titration, and the process of filtration and washing 
can be completed in from twenty to thirty minutes. The ammonium 
urate is washed into a beaker, after opening the filter, using about 
100 c.c. of water. Fifteen c.c. of concentrated sulphuric acid are 
then added, and the solution is titrated at once with a one-twen- 
tieth normal solution of potassium permanganate. Toward the end 
of the titration Folin suggests to add the permanganate in portions 
of two drops at a time, until the first trace of a rose color is apparent 
throughout the entire fluid. Each cubic centimeter of the reagent 
corresponds to 0.00375 gramme of uric acid. A final correction of 
0.003 gramme for each 100 c.c. of urine employed is necessary, 
owing to the slight extent to which ammonium urate is soluble. 

Preparation of the One-twentieth Normal Solution of Potassium 
Permanganate. — As the molecular weight of potassium perman- 
ganate is 157.67, one would expect that a normal solution of the 
salt should contain this amount in grammes dissolved in 1000 c.c. 
of water. But the substance generally acts in the presence of free 
acids, upon deoxidizing substances, by losing 5 atoms of oxygen 
of the 8 atoms contained in 2 molecules, as is seen in the following 
equation : 

2KMnO, + 5H. 2 C,0 4 + 3H 2 S0 4 = K 2 S0 4 + 2MnS0 4 + 10CO 2 + 8H 2 0. 

It follows that two-fifths of the molecular weight, or 63.068 
grammes, are the equivalent of 1 oxygen atom. But as oxygen 
is diatomic and the volumetric normal is calculated for monatomic 

1 O. Folin u. A. Shaffer, Zeit. f. physiol. Chem., vol. xxxii. p. 552. 



CHEMISTRY OF THE URINE. 379 

values, this Dumber must be divided by '2, and 31.534 grammes 
of potassium permanganate should therefore be present in 1 liter 

of UOrmal solution. A one-tenth normal solution would hence 
contain 3.1534 grammes, and a one-twentieth normal solution 
1.576 grammes pro liter. This amount is weighed oh 1 ' and dis- 
solved in 950 c.c. of water, when the solution is brought to the 
proper degree of dilution (see page 322) by titration with a one- 
twentieth normal solution of oxalic acid. A one-twentieth normal 
solution of oxalic acid contains 3.142 grammes of the acid in 1000 
c.c. of water. One c.c. of the one-twentieth normal solution of 
potassium permanganate should correspond to 1 c.c. of the oxalic 
acid solution. The titration is best conducted by diluting 10 c.c. 
of the oxalic acid solution to 100 c.c. with distilled water and add- 
ing L5 c.c. of concentrated sulphuric acid, so as to bring the tempera- 
ture of the liquid to from 55° to 66° C. The potassium perman- 
ganate solution is then added drop by drop until the red color no 
longer disappears on stirring, but persists for at least thirty seconds. 

Titration with Sodium Hydrate Solution. — This method is not as 
accurate as the one just described, but suffices for ordinary purposes. 
The uric acid is precipitated with an ammonium salt, as above. 
After standing for two hours the ammonium urate is filtered oil', 
washed with a 10 per cent, solution of ammonium sulphate, and 
brought into a beaker with the aid of a small amount of hot water. 
The salt is then decomposed by the addition of from 10 to 15 c.c. 
of a one-tenth normal solution of hydrochloric acid. The mixture 
is brought to the boiling-point, and the hydrochloric acid not used 
in the decomposition of the ammonium urate retitrated with a one- 
tenth normal solution of sodium hydrate, using dimethyl-amido- 
azo-benzol as an indicator. The amount of hydrochloric acid found 
i> deducted from the 10 or 15 c.c. added, and the result multiplied 
by 0.0168. The amount of uric acid contained in the original 
quantity of urine is thus ascertained, to which 0.003 gramme is 
added for each 100 c.c. of urine used, as above. 

Gravimetric Method. — The process is begun as described above. 
The ammonium urate is decomposed by the addition of from 2 to 3 
c.c. of a 25 per cent, solution of hydrochloric acid. This solution 
i< evaporated until crystals of uric acid begin to separate out. These 
are collected on a dried and weighed filter, and washed successively 
with water, alcohol (90-95 per cent.), and absolute alcohol, and 
finally with ether. The mother-liquor and water used in washing 
are carefully measured, and 0.0004 gramme added to the final resull 
for each 10 c.c 

Haycraft's Method. 1 — This method is based upon the precipitation 
of uric acid with an ammoniaeal silver solution and magnesia mixt- 
ure, 1 molecule of silver corresponding to 1 molecule of uric acid. 

1 I la vera ft, Zeit. f. analvt. (hem., vol. xxv. 



380 THE URINE. 

As the amount of silver thus precipitated can be determined by titra- 
tion with a solution of potassium sulphocyanide, the corresponding 
amount of uric acid is readily found. 

Solutions required: 1. An ammoniacal silver solution. 2. An 
ammoniacal magnesia mixture. 3. A one-fiftieth normal solution 
of silver nitrate. 4. A one-fiftieth normal solution of potassium 
sulphocyanide. 

Preparation of these solutions : 

1. The ammoniacal silver solution is prepared by dissolving 26 
grammes of silver nitrate in distilled water, and adding enough 
ammonia to redissolve the brown precipitate of argentic oxide which 
is first formed ; distilled water is then added in sufficient amount to 
make the total quantity 950 c.c. This solution is brought to the 
proper strength by titrating a known amount of sodium chloride, as 
described elsewhere. Each cubic centimeter then contains 0.026 
gramme of silver nitrate, which is equivalent to 0.0169 gramme of 
silver. 

2. The ammoniacal magnesia mixture is prepared by dissolving 
100 grammes of crystallized magnesium chloride in a sufficient 
amount of water ; to this a cold saturated solution of ammonium 
chloride is added in excess, and sufficient strong ammonia to impart 
a decided odor. Should the mixture not be perfectly clear, more 
ammonium chloride solution is added. The solution is then diluted 
with water to 1 liter. 

3. The one-fiftieth normal solution of silver nitrate is prepared 
by dissolving 3.4 grammes of silver nitrate in 950 c.c. of distilled 
water, the degree of further dilution being determined as described 
elsewhere. 

4. To prepare the one-fiftieth normal solution of potassium sul- 
phocyanide, about 2 grammes of the salt are dissolved in 950 c.c. 
of water ; the solution is brought to the required strength, so that 1 
c.c. shall correspond to 1 c.c of the silver solution. 

For filtering the uric acid, a perforated platinum cone is placed in 
a small funnel and packed with a thin layer of glass-wool, upon 
which in turn a layer of finely scraped asbestos is placed. The 
asbestos is previously thoroughly washed with dilute hydrochloric 
acid and subsequently with distilled water until every trace of chlo- 
rine has disappeared. When properly prepared, the asbestos forms 
a mould of the cone. 

Method. — Five c.c. of the ammoniacal silver solution are mixed 
with 5 c.c. of the ammoniacal magnesia mixture. Ammonia is then 
added until the solution is clear, when it is poured into 50 c.c. of 
urine. As soon as the precipitate has settled the supernatant liquid 
is passed through the prepared filter with the aid of a suction-pump. 
About 4 grammes of sodium bicarbonate in coarse pieces are now 
placed upon the filter and the precipitate is added ; the sodium bicar- 



CHEMISTRY OF THE URINE. 381 

bonate serves the purpose of aiding filtration by loosening the pre- 
cipitate. This is now washed free from chlorine and silver by means 
of ammoniacal water, using the suction-pump until the precipitate 
appears broken in places, then without the pump, using this only at 
last to remove the last drops of liquid. (Test for silver with very 
dilute hydrochloric acid, and for chlorine with a solution of silver 
nitrate and nitric acid.) The precipitate is now dissolved on the 
filter by means of nitric acid of 20 to 30 per cent. The nitric 
acid must be free from nitrous acid. This is secured by allow- 
ing it to stand in contact with pure urea until any evolution of 
gas has ceased. The filter is washed with very dilute nitric acid 
and then with distilled water until this no longer shows an acid 
reaction. The solution thus obtained is titrated with the one-fiftieth 
normal solution of potassium sulphocyanide, using ammonio-ferric 
alum as an indicator. As each cubic centimeter of this solution 
indicates 0.0160 gramme of silver, and as 1 molecule of silver 
indicates 1 molecule of uric acid — i. e., 108 grammes of silver 168 
grammes of uric acid — 0.0169 gramme of silver, corresponding to 
1 c.c. of the potassium sulphocyanide solution, represents 0.2629 
gramme of uric acid. 

Ludwig-Salkowski Method. — Principle. — The method is based upon 
the formation of insoluble magnesium-silver urate when a solution 
of uric acid in sodium carbonate is treated with a solution of silver 
nitrate after the previous addition of an excess of ammonia. This 
is then decomposed, with the liberation of free uric acid. 

Method. 1 — Two hundred and fifty c.c. of urine are treated with 
50 c.c. of ammoniacal magnesia mixture (see above) to remove the 
phosphates. The magnesia mixture is employed for the reason that 
the compound of uric acid with magnesium and silver which is 
formed later on is not decomposed so easily as the sodium or the 
potassium compound, which would occur if the urine were pre- 
cipitated only with ammonia. The mixture is then immediately 
filtered, as otherwise a little magnesium urate would be precipitated. 
Two hundred and fifty c.c. of the filtrate, corresponding t<> 200 c.c. 
of urine, are measured off as soon as possible, and treated with a 
few cubic centimeters of a 3 per cent, solution of silver nitrate. If 
the precipitated silver chloride formed in the beginning does not dis- 
appear on stirring, a little more ammonium hydrate is added. A 
flaky precipitate next separates out. and is allowed to settle. In 
order to test whether enough of the silver nitrate solution has been 
added, a few cubic centimeters of the supernatant fluid are acidified 
with nitric acid. If a distinct cloudiness, referable to silver 
chloride, appears, enough has been added. Otherwise the lew cubic 
centimeters that were employed for this test are rendered alkaline 

1 E. Salkowsld. S;ilkow>ki u. Leube, Die Lehre vom Ham. E. Lndwig, Wien. cued. 

Jahrbiicher. 1884, p. 597. 



382 THE URINE. 

again with ammonia, poured back, and treated with more silver 
solution until the required amount has been reached. The liquid 
is then rapidly filtered through a folded filter of rather loose paper, 
a feather or rubber-tipped glass rod being used for the purpose of 
removing all the precipitate from the beaker. The precipitate is 
washed with ammoniacal water until a specimen of the washings 
is no longer rendered turbid by nitric acid, and only faintly so by 
the addition of a drop of silver solution. The filter with the pre- 
cipitate is next placed in a wide-mouthed flask, containing about 
200 c.c. of distilled water, and thoroughly agitated. Hydrogen 
sulphide is then passed through the mixture. It is now brought to 
the boiling-point and rendered distinctly acid by means of a few 
drops of hydrochloric acid, when the argentic sulphide and the 
paper are rapidly filtered off, as otherwise there will be an admixture 
of sulphur with the uric acid. The contents of the filter are washed 
a few times with hot water. Filtrate and washings are quickly 
evaporated to a few cubic centimeters, treated with a few drops of 
hydrochloric acid, and set aside in a cool place for twenty-four 
hours. Occasionally it happens that upon addition of the hydro- 
chloric acid a cloudiness appears, which is due to an admixture of 
sulphur. In such a case the dried uric acid must be washed with 
carbon disulphide. Otherwise the uric acid that has separated out 
is directly collected on a dried and weighed filter, and washed suc- 
cessively with water, 90 to 94 per cent, alcohol, and finally with 
absolute alcohol and ether. The water used in washing should be 
collected separately, and for each 20 c.c. used 0.0048 gramme added 
to the weight of the uric acid obtained. 

Precautions : 1. Rapidity in working is essential. 

2. Very concentrated urines must be diluted one-half before com- 
mencing the examination. 

3. If the specific gravity of the urine is low, it should be con- 
centrated to a specific gravity of about 1.020. 

4. If the urine shows a sediment of uric acid, this should be 
separately collected and weighed, and the weight obtained added to 
the final result. 

5. Any albumin that may be present must be previously removed. 

6. If sugar is present in the urine, about 500 to 1000 c.c. are 
treated with a solution of neutral lead acetate, filtered, and the 
filtrate precipitated with mercuric acetate. The precipitate thus 
formed, Avhich consists essentially of mercuric urate, is filtered off 
after having stood for twelve to twenty-four hours, then washed, and 
later suspended in water. The mercury is removed by means of 
hydrogen sulphide, the mercuric sulphide filtered off, and the filtrate 
collected and set aside. The precipitate itself is thoroughly boiled 
with water and again filtered, the washings thus obtained being 
added to the filtrate set aside, as just described. The total amount 



CHEMISTRY OF THE URINE. 383 



of fluid is thou evaporated to a small volume and acidified with 
hydrochloric acid, when the uric acid will separate out and may be 
treated as previously directed. 

The Xanthin-bases. 

The xanthin-bases which have been found in the urine arc xanthin, 
hypoxanthin, heteroxanthin, paraxanthin, guanin, and adenin. Con- 
jointly they are also spoken of as the alloxur bases, or purin bases. 
Together with uric acid they are termed alloxur or purin bodies. 
Their relation to uric acid and the nueleins has already been con- 
sidered (see page 371). Unlike uric acid, they also occur as such 
in animal as well as vegetable tissues. The amount which appears 
in the urine under normal conditions is very small, constituting 
about 10 per cent, of the uric acid. Larger quantities may be met 
with in various diseases, and, generally speaking, an increase in the 
amount of uric acid is associated with an increase of the xanthin- 
bases. This is, however, not invariably the case, and at times it 
may be observed that an increase of the uric acid is accompanied by 
a diminution of the xanthins, and rice versa. These varying rela- 
tions can, of course, be readily understood if we remember that uric 
acid is an oxidation-product of the xanthin-bases, and that their 
ultimate origin is the same. 

The literature which deals with the elimination of the xanthin- 
bases in various diseases has during the past few years assumed 
enormous proportions. This has largely been owing to the publica- 
tion by Kruger and "NYulff of a relatively simple method for their 
quantitative estimation. Unfortunately, however, this method has 
proved unreliable and the results obtained incorrect. Our knowl- 
edge of the relation of the xanthins to pathological processes is 
hence as defective at the present time as it was years ago. 

Individually the xanthin-bases are of little clinical interest. 
Xanthin has once been found in a urinary sediment, and has in 
several instances beeo encountered as the principal constituent of 
vesica] calculi. Its normal quantity is said to vary between 0.02 
and 0.03 gramme. Larger quantities are found after a meal rich 
in nueleins, in leuka?mia, nephritis, pneumonia, etc. 

Paraxanthin and heteroxanthin are present only in traces, as is 
apparent from the fact that Kruger and Salomon were able to obtain 
but T.o grammes of heteroxanthin from 10,000 liters of urine. 
Both apparently are distinctly toxic. 

Xanthin sediments may be recognized by means of the following 
test : a small amount of the material is treated with a few drops of 
concentrated nitric acid on a porcelain plate, and evaporated to dry- 
ness. In the presence of xanthin a yellow residue is obtained, which 
turns red upon the addition of a few drops of sodium hydrate solu- 



384 THE URINE. 

tioii and the application of heat. The reaction is common to all the 
xanthins. 

Quantitative Estimation. — Salkowski's Method. 1 — Six hundred 
c.c. of mine are precipitated with 200 c.c. of magnesia mixture 
(see page 380), when a 3 per cent, anunoniacal solution of 
silver nitrate is added to from 700 to 750 c.c. of the nitrate. 
The proportion should be 6 c.c. for each 100 c.c. of urine. 
The silver nitrate solution should be added as described on 
pap;e 381. After standing for one hour the mixture is filtered, and 
the precipitate washed with water until all the free silver has been 
removed. The filter is then perforated, the precipitate washed into 
a flask with from 600 to 800 c.c. of water, acidified with hydro- 
chloric acid, and decomposed with hydrogen sulphide. The excess 
of hydrogen sulphide is removed by heatiug on a water-bath, when 
the silver suphide is filtered otf and the filtrate evaporated to dryness. 
The residue is treated with from 25 to 30 c.c. of dilute sulphuric 
acid (1 : 100). This solution is brought to the boiling-point and is 
allowed to stand over night. The uric acid which has then sepa- 
rated out is filtered otf, washed with a small amount of dilute sul- 
phuric acid (not more than 50 c.c). then with alcohol and ether, and 
weighed. To the resulting weight Q.0005 sTamrae is added for 
each 10 c.c. of the acid filtrate, to allow for the trace of uric acid 
which is thus lost. 

After having filtered off the uric acid the filtrate is again treated 
with ammonia and silver solution, and the xanthin-bases thus pre- 
cipitated. The precipitate is collected on a small filter, washed with 
water, dried, and incinerated. The ash is dissolved in nitric acid, 
and the silver estimated by titration with a solution of potassium 
sulphocyanide, using ammonio-ferric alum as an indicator (see page 
320). The solution of potassium sulphocyanide employed in the 
estimation of the chlorides may be used, and is of such strength 
that 1 c.c. corresponds to 0.00734 gramme of silver. As 1 atom 
of silver in a mixture of the silver compounds of guanin, xanthin, 
hypoxanthin, etc., represents 0.277 gramme of nitrogen, or 0.7381 
gramme of the alloxur bases, it is apparent that 1 c.c. of the potas- 
sium sulphocyanide solution will represent 0.002 gramme of nitro- 
gen and 0.00542 gramme of alloxur bases. In every case an accu- 
rate record most, of course, be kept of the amount of urine and 
filtrate used. 

The amount of alloxur bases found by Salkovrski in the normal urine 
of twenty -four hours varied between 0.0286 and 0.0561 gramme. 

Literature. — M. Kriiger n. Gr. Salomon. ''Die Alloxurbasen d. Hams.** Zeir. f. 
physiol. Chem.. vol. xxiv. p. 364, and vol. xxvi. p. 343: Deutsch. med. Woch.. 15^9. p. 
97. Bondsynski u. Gottlieb. " Ueher Xanthinkorper im Ham des Leukamiker." Arch, 
f. exper. Path. u. Pbarmakol.. 1595. vol. xxxvi. p. i.3'2. F. Gumprecbt. " A^oxurkorper 
u. Leukoeyten.'" Centralbl. f. alls. Path. u. path. Anat.. 1596. vol. vii. p. 5"20. 

1 E. Salkowski. Pfltiger's Archiv. vol. lxix. p. 268. 



CHEMISTRY OF THE URINE. 385 

Hippuric Acid. 

Hippuric acid is a constant constituent of normal urine, 0.1 to 1 
gramme being excreted in the twenty-four hours. That it is derived, 
to some extent at least, from albuminous material is proved by the 
fact that its elimination is not suspended during starvation nor during 
the administration of a purely albuminous diet. The manner in 
which hippuric acid is formed in the body-economy, however, has 
not been definitely ascertained. In vitro it may be obtained from 
glycocoU and benzoic acid, according to the equation 

c t; i r 6 CH 2 X i r a CH,NH - C 6 H 5 CO 

I +| =| +H 3 0. 

coon cooh cooh 

Benzoic acid. GlycocoU. Hippuric acid. 

It has beeu shown that phenyl-propionic acid, which differs from 
benzoic acid by the group C 2 H 4 , and which latter may be regarded 
as phenyl-formic acid, is produced during the process of intestinal 
putrefaction. The relation between the two bodies is seen from the 
formula? : 

H C 6 H 5 CH 3 CH 2 .C 6 H 5 

I »-» I I I 

COOH COOH CH 2 »— > CH 2 

Formic Phemi-formic 
acid. acid. COOH COOH 

Propionic Phenyl-propionic 
acid. acid. 

Phenyl-propionic acid is then absorbed into the blood and there, 
according to our present ideas, transformed into phenyl-formic acid 
or benzoic acid. When the latter comes in contact with glycocoU, 
which is probably also produced during the process of intestinal 
putrefaction, an interaction between the two substances occurs in 
the body, hippuric acid resulting, as shown in the above equation. 
This view is supported by the fact that phenyl-propionic acid, just 
as benzoic acid, when introduced into the circulation of certain ani- 
mals, reappears in the urine as hippuric acid. The final proof of 
the possible synthesis of hippuric acid from glycocoU and benzoic 
acid in the body has been furnished by Bunge and Schmiedeberg, 1 
who obtained this substance, when arterialized blood containing 
glycocoU and sodium benzoate was allowed to pass through isolated 
kidneys of dogs. 

Not all the hippuric acid eliminated, however, is referable to albu- 
minous decomposition, but a considerable portion is derived from 
benzoic acid or its derivatives, which occur in many fruits, and 
are transformed into hippuric acid in the body. Among those 
which are particularly rich in these substances may be mentioned 

1 Schmiedeberg u. Bunge, Arch. f. exper. Path. u. Pharmakol., vol. vi. 
25 



386 THE URINE. 

the red bilberry, prunes, coffee-beans, reinesclaudes, etc., and in all 
cases in which an increased elimination of hippuric acid is observed 
the possibility of this source must always be taken into account. 

As to the seat of this synthesis there appears to be some uncer- 
tainty, as it is apparently not the same in all animals. In the dog 
and the frog the kidneys, according to the researches of Bunge and 
Schmiedeberg, must be regarded as the principal and possibly the 
only organs in which this process occurs. As Salomon, however, 
has demonstrated the presence of hippuric acid in the muscles, liver, 
and blood of nephrectomized rabbits, still other organs must, in the 
herbivora at least, be concerned in its production. 

Very little is known of the pathological variations in the excre- 
tion of hippuric acid ; this is principally owing to the fact that until 
recently suitable methods for its quantitative estimation were not 
available. It is an interesting fact that, in accordance with Bunge's 
experiments in dogs, the formation of hippuric acid appears to be 
suspended in cases of acute as well as chronic parenchymatous 
nephritis, for the benzoic acid which is then ingested reappears 
in the urine unchanged. In amyloid degeneration a marked dimi- 
nution in its amount has likewise been demonstrated. Large quan- 
tities of hippuric acid, on the other hand, have been noted in acute 
febrile diseases, hepatic diseases, diabetes mellitus, chorea, etc. The 
data, however, are insufficient to warrant any definite conclusions at 
the present time. 1 

Properties of Hippuric Acid. — Chemically, hippuric acid must 
be regarded as benzoyl-amido-acetic acid, C 9 H 9 X0 3 — (C ri H 5 .COXH. 
CH o .C00H). It crystallizes in long rhombic prisms when allowed 
to separate from its solutions gradually, while it forms long needles 
if crystallization takes place rapidly and the amount is small (Fig. 
95). In cold water and ether it is soluble with difficulty, while it 
dissolves readily in hot water, in alcohol, and in aqueous solutions 
of the hydrates and carbonates of the alkalies, with which it forms 
salts, and from which the acid may again be separated and caused 
to crystallize out by adding a stronger acid. 

\Yhen hippuric acid or one of its salts is evaporated to dryness 
with concentrated nitric acid and the residue is heated, the odor of 
bitter almonds is noticed ; this is due to the formation of nitro- 
benzol. 

AYhen boiled with hydrochloric acid or dilute sulphuric acid 
hippuric acid is decomposed into glycocoll and benzoic acid. A 
similar decomposition is effected during the process of putrefaction, 
and hence no hippuric acid is found in decomposing urine, benzoic 
acid taking its place. The latter is always found in the urine 
together with hippuric acid, but has no clinical significance. In 

1 Th. Weyl u. B. von Anerep, " Ueber die Ausscheidmisr der Hippursiiure und Ben- 
zoesaure wabrend des Fiebers," Zeit. f. pbysiol. Chem., 1SS0, vol. iv. p. 169. 



CHEMISTRY OF THE URINE. 



387 



larger amounts it has recently been encountered in a case of diabetes. 
It crystallizes in needles or lustrous Lamina?, presenting ragged 
edges, which resemble plates of cholesterin. It is soluble with 
difficulty iu cold water, but easily soluble in ether, alcohol, and solu- 
tions of the alkaline carbonates and hydrates, forming salts with the 
latter. 

Hippuric acid in the urine occurs iu combination with sodium, 
potassium, calcium, aud magnesium. 

Quantitative Estimation of Hippuric Acid. — The following 
method, which may be employed for the quantitative estimation of 
hippuric acid, although tedious, must also be employed when it is 
desired to test for its presence. 

Principle. — Hippuric acid readily dissolves in solutions of the 
alkaline hydrates and carbonates, forming salts. These are decom- 
posed by means of a stronger acid, w r hen the hippuric acid which 
separates out is collected and weighed. 



Fig. 95. 




Hippuric acid crystals. 



Method. — Five hundred to 1000 c.c. of fresh urine are evap- 
orated to a syrupy consistence on a water-bath, care being taken to 
keep the urine neutral by the addition of sodium carbonate. The 
residue is extracted with cold alcohol (90 to 95 per cent.), using 
about half of the quantity as that of the urine employed. The 
mixture is then set aside for twenty-four hours. The alcoholic 
filtrate, which contains the salts of hippuric acid, is freed from 
alcohol by distillation. The remaining solution is strongly acidified 
with acetic acid and extracted with at least five times its volume of 
alcoholic ether (1 part of alcohol to 9 parts of ether). From the 
combined extracts the ether is distilled off and the remaining solu- 
tion evaporated on a water-bath. The resinous residue is boiled 
with water, set aside to cool, and filtered through a well-moistened 



388 THE URINE. 

filter. The hippuiic acid, which is easily soluble in boiling water, 
is thus separated from other constituents which are soluble in alco- 
hol and ether. The filtrate is rendered alkaline with a little milk 
of lime, any excess of calcium being removed by passing carbon 
dioxide through the mixture. This is then brought to the boiling- 
point and filtered. Any impurities which may be present are re- 
moved bv shaking with ether. The calcium salts remaining in solu- 
tion are decomposed by means of an acid, when the solution is again 
extracted with ether. The remaining solution is evaporated to a few 
cubic centimeters, when the hippuric acid will separate out on stand- 
ing. The crystals are dried on plates of plaster of Paris, shaken 
with benzol or petroleum-ether to remove any benzoic acid, and 
finally weighed. These crystals may be shown to be hippuiic acid 
by their microscopical appearance, their solubility in alcohol, and 
their behavior when evaporated with concentrated nitric acid, as 
indicated above. 

Hofmeister's Method. — Two hundred to 300 c.c. of mine are evap- 
orated in a glass dish to one-third of the original volume, and 
treated with 4 grammes of disodiuni phosphate, to transform the 
acid into its sodium salt. The mixture is evaporated to a syrupy 
consistence, the residue treated with burnt gyp sum, dried thoroughly, 
and pulverized together with the dish. The powder is extracted in 
a Soxhlet apparatus with freshly rectified petroleum-ether (boiling- 
point 60° to 80° C.) for forty-six hours, and then for six to ten 
hours with pure ether (free from water and alcohol). After dis- 
tilling off the ether the residue is dissolved in boiling water and 
decolorized with animal charcoal, the latter being subsequently 
thoroughly washed with boiling water ; the solution and washings 
are evaporated to about 1 or 2 c.c. at a temperature of from 50 c to 
60° C, and set aside to crystallize. The crystals of hippuric acid 
are finally washed with a few drops of water and ether, and weighed. 

Kreatin and Kreatinin. 

Kreatin, which is constantly present in muscle-tissue, is in all 
probability the immediate and constant antecedent of kreatinin. so 
that two sources of this body must be recognized, viz., the muscle- 
tissue of the body and the muscle-tissue ingested as food. Beyond 
this, however, practically nothing is known, and as the artificial pro- 
duction of kreatinin from albuminous material has never been 
accomplished, it is hardly warrantable to venture an hypothesi- as to 
its mode of formation in the body. 

Kreatinin is a constant constituent of the urine, about 1 gramme 
being excreted daily by a healthy adult. Pathologically, variations 
in this amount have been observed, but the data obtained possi ss 
little value. Before drawing conclusions from observations made in 



CHEMISTRY OF THE URINE. 389 

the clinical laboratory it is necessary to take into account the quan- 
tity of meat ingested; as a meat-diet will greatly increase the amount 
of kreatinin. It' then in patients affected with acute; febrile dis- 
eases, such as pneumonia, typhoid fever, etc., a large increase is 
observed, the patient being at the same time upon a milk-diet, an 
increased destruction of muscle-tissue may be inferred, as a milk- 
diet in itself, cceteris paribus, causes a diminished elimination. A 
decrease would logically be expected to occur during convalescence 
from such diseases. In the various forms of anaemia, marasmus, 
chlorosis, phthisis, etc., a diminished amount is observed. 1 

The transformation of kreatin into kreatinin has been supposed to 
take place in the kidneys, a view which accords with the greatly 
diminished excretion of kreatinin in advanced cases of chronic 
parenchymatous nephritis. In progressive muscular atrophy, in 
pseudohypertrophic paralysis, and in progressive ossifying myositis 
a diminution has also been noted. 

Properties of Kreatin and Kreatinin. — Chemically, kreatin may 
be regarded as a methyl derivative of glucocyamin, which latter is 
guanidin in which 1 XH 2 group has been replaced by glycocoll. 
Kreatinin, on the other hand, is the methyl derivative of glucocy- 
amidin, which differs from glucocyamin only in the absence of 1 
molecule of water, so that kreatinin is kreatin minus 1 molecule of 
water, both being derivatives of guanidin. The relation between 
the various bodies is shown below : 

/NH a 

C=KH 

\*H 2 
Guanidin. 

/NH 2 /NH 2 

C=NH C=NH 

\NH.CH 2 .COOH \N(CH 3 ).CH 2 .COOH 

Glucocyamin. Kreatin. 

/NH /NH 

C=NH C=N 

XJI.CH 2 .CO \N(CH,).CH 2 .CO 

Glucocyamiciin (glucocyamin minus water). Kreatinin (kreatin minus water). 

Kreatinin crystallizes without water of crystallization in colorless, 
glistening prisms. At times, when the crystals are not well devel- 
oped, it also appears in the form of whetstones. It is readily soluble 
in hot and also quite soluble in cold water and hot alcohol ; in cold 
alcohol and ether it dissolves with difficulty. It forms salts with 
acids, and double -alt- with some of the salts of the heavy metals. 
Among these maybe mentioned kreatinin hydrochloride, C ( II 7 X ;! (). 
HC1, which is easily soluble in water and crystallizes in the form of 
transparent prisms or rhombic plates. Most important is the com- 

1 C. E. Simon, Physiological Chemistry, Lea Bros. & Co., 1901. Senator, Virchow'a 
Archiv, 1876, vol. lxvii. p. 422. Neubauer u. Vogel, Harnanalyse, I't. ii. 



390 



THE UEIXE. 



pound of kreatinin with zinc chloride, (C 1 H 7 X 3 0) 2 .ZnCl 2 (Fig. 96). 
This is produced when a watery or alcoholic solution of kreatinin is 
treated with zinc chloride. The crystalline form of this compound 
depends greatly upon the purity of the kreatinin solution. AVhen 
obtained from alcoholic extracts of the urine it occurs in the form 
of varicose conglomerations which often adhere firmly to the walls 
of the vessel. If the solution of kreatinin is perfectly pure, how- 
ever, it is seen in the form of fine needles grouped in rosettes or 
sheaves. Kreatinin-zinc chloride is soluble with much difficulty in 
water and insoluble in alcohol. The compound is especially impor- 
tant, as upon its formation and properties the quantitative estimation 
of kreatinin in the urine is based. Silver nitrate and mercuric chlo- 
ride cause a precipitation of kreatinin, and may, therefore, also be 
employed for the purpose of obtaining the substance from the urine. 



Fig. 96. 




Crystals of kreatinin-zinc chloride. (Salkowski.) 

Test for Kreatinin in the Urine. — A few cubic centimeters of 
urine are treated with a few drops of a very dilute solution of sodium 
nitroprusside and then drop by drop with a dilute solution of sodium 
hydrate. In the presence of kreatinin the urine assumes a ruby-red 
color, which is particularly well seen in the lower portion of the 
tube. This color disappears after a few minutes, and is replaced by 
an intense yellow, which on warming with glacial acetic acid in pure 
solutions turns to green, then to blue, and on standing a deposit of 
Prussian blue is obtained ( WeyVs test)} The presence of albumin 
or sugar does not interfere with the reaction. 

Quantitative Estimation of Kreatinin in the Urine. 2 — Prin- 
ciple. — AVhen an alcoholic extract of urine is treated with an alco- 



1 Th. Wevl. Ber. d. deutsch. chem. Gesellsch., 1378. vol. xi. p. 21 
f. physiol. Chem.. 1886, vol. x. p. 399. 



and Jaffe, Zeit. 
2 Leube u. Salkowski, Die Lehre vom Ham. Hirschwald, Berlin, 1882, p. 111. 



CHEMISTRY OF THE URINE. 391 

holic solution of zinc chloride kreatinin-zinc chloride separates out. 
This, as lias been mentioned, is almost insoluble in alcohol. Know- 
ing the molecular weight of kivatinin and kreatinin-zinc chloride, 
the calculation of the amount of kreatinin becomes a simple matter. 
The molecular weight of kreatinin is 113, that of kreatinin-zinc 
chloride 362. In 362 parts by weight of the latter there are, hence, 
226 parts by weight of kreatinin, so that the amount of the kreatinin 
may be calculated from the weight of the kreatinin-zinc chloride 
according to the following equation : 362 : 226 : : y : x ; and x — 
0.6243//, in which y indicates the weight of the kreatinin-zinc 
chloride found, and x the corresponding amount of kreatinin. The 
phosphates must, of course, first be eliminated, as insoluble zinc 
phosphate would otherwise be precipitated. 

Method. — In 200 c.c. of urine the phosphates are first removed 
by alkaliniziug with milk of lime, and then adding calcium chloride 
so long as a precipitate forms. If the volume is now less than 
300 c.c, water is added to that amount. The mixture is filtered 
after having been allowed to stand for from one-quarter to one- 
half hour, and washed with a little water. Filtrate and washings 
are slightly acidified with dilute hydrochloric acid, so as to prevent 
the transformation of kreatinin into kreatin, and evaporated on 
a water-bath to a syrupy consistence, and then thoroughly mixed 
with 20 to 30 c.c. of absolute alcohol. The mixture is poured into 
a stoppered flask provided with a 100 c.c. mark, and after thor- 
oughly rinsing out the evaporating-dish with absolute alcohol the 
washings are also placed in the bottle, and absolute alcohol is added 
to the mark. The bottle is thoroughly shaken and set aside in a cool 
place for twenty-four hours, the mixture being agitated from time to 
time. It is now filtered and rendered slightly alkaline with a drop 
or two of a sodium carbonate solution, as kreatinin hydrochloride is 
not precipitated by zinc chloride. The reaction, however, should 
be only faintly alkaline, as otherwise zinc oxide will be precipitated. 
The mixture is now slightly acidified with acetic acid and treated 
with 0.5 c.c. of an alcoholic solution of zinc chloride, prepared by 
dissolving the salt in 80 per cent, alcohol and diluting with 95 
per cent, alcohol to a specific gravity of 1.2. The mixture is well 
stirred and set aside in a cool place for two or three days. The 
crystals, which are usually deposited on the sides of the vessel in 
the form of wart-like masses, are then collected upon a dried and 
weighed filter, always using portions of the filtrate 1 to bring the 
crystals completely upon the filter. These 1 are washed with a small 
amount of 90 per cent, alcohol, until the washings are without color 
and giveonlv a slight opalescence when treated with a drop of silver 
nitrate solution. The crystals are finally dried at a temperature 
of 100° C, and weighed. By multiplying the weight thus found by 
0.6243 the amount of kreatinin is obtained. 



:: . i 



: . the - -:-:. i 

iiri .nil- 1 ±1 mi : i _ - it: 
rin ■"-.-'.. i_ ii -n iiiie- :i i- e- 
sugar by fennenfcaiioii, to take one-fifth 

mei in — -H17-1: 1: i:it-. ii: :: hi 
It: 1- 111: ~\i_- 11 in: ■] _::-- 

_ I_t "-._„ 1.11.. -i - Tiiiirm. - 

: - - - 1:1 1 - - : - ...:_._.:. - . :-. 11-1: 

liii - 11 - :: i* : ---..- - -:t:i__1t m iz 1: 
: : :. . - : : : -: _ir 11- 11111111 nn 11: - 1 ni- 
ti" :_t 11-11 .1-:.::. : 11 11 .'.t 1 7"". .;■ ". : -. : 1 "-••- :: - : '--- 
1111 1 : 1 -in'i iiri i::i Tn :■--. : ...- - _i 11-1 ne: :i::. .:-■". 
~ii. — . 11 "ii-m ii: ii-n 1,. :i. .1 —-. -Mil 

A; lOi Ttin- : 1 : m-: _ :i . - . 1 - - 1 : _ _ - 1:1- 

m riirJi: : 11: 1: I- :_- : :::-i:i:„i. in 11: :: i_t :■ mmii _ 

I : ■ _ - -. : : - : - .__ . ni :i _. - 1 - . 

i-i i = - - ' -_ :i > .-. ; t -~m :_t .1. zi :: ' ziz: 11 ~ 

: - ._ 1: : 1- i__-:m: 1111 

j_ ■" 1. _." " :i_. : ~~~~ 1: :.. .- :. - : ;: Lzii ' _— . zzi imizz: 
: : 11 : zniz : - : iz .". 

3. Instead of doing tMs, the predLp&ate in the alcohohe solution 
may be examined nueroscopieally before filtering. If sodium ehlo- 

-. 
:. - - ' 1 -.■-.' - : : 1 - --- • - ' , 7 - im . _. : . ' . - _ . - - - ' .-- 

=••:•_ -ei 1 -in"- i ~ 1: ; 1 : 1: ini 1. 

4. If the crystals of kieatinin-zine chloride adhere very firmly 
: n~ -.".--- : :br t^.^ - 1 : 1111 rimi-i — i: V ::: ht.tZ 

- perhaps best to dissolve them in a little hot water, to evaporate 
11-- : ~~i~ :i i-T-iiii: 1 111 

I: 11 iriz-7 si - 1 : m '. . 7 : 7- .- :: :• im ilifj 
~zm -I'-iri nil .: 1 „ :' — : 1 _. 1 zz i 1: ieiiri rni '::, :._ -: 
- _ -- - :— -: :-: ijmz-: ii_ 11" -i: 1:1 :„ : zi: - -i - It—i: iz: 
1:7:11.1 17: :_: 7i.::..:ni :- ii:.^.. :- ies:ri:ei 

Oxalic Acid. 

7:z : 1.1 :' i:i. : i::i :i 1 :„ ~ :i :i 1 7— - ' ' : 7 - ^i: :-: 
7- 111 1: - .: : 1 "i-"- : 11:1 ii 1:^----- :••" 1 11- 1 
evi deooe to show that a «eriain amount is also fbtmed doling the 
mi 1-1 :"ii- ,~ ---^- - ■ : - ' 1 tii in ii-iiii 1 "ii-7-" 

II Ti niii. > •:-•::-- — : 1.1 11 -e 1 mil- - »••• 
do not enter into oonsideiation. TTrie addL, howerier 9 which, a- 

• - - 

oiddizsd to oxalie acid, with the intennediaiy fomaataoe of paiahanie 
acid and L The latter indeed has been repeatedly dem- 

onstiated in the urine, and it is eoncewable that the isame pr • 

'_ - . . _ - - - - 






CHEMISTRY OF TEE URINE. 393 

acid which is obtained from the urine is formed artificially during 
the lengthy process of separation, and that the substance did not 
exist preformed, there is no reason for the assumption thai uric acid 
may not be the normal antecedent of the oxalic acid after all. For 
Salkowski has demonstrated conclusively that on oxidation with 
ferric chloride in aqueous solution uric acid yields oxalic acid and 
urea directly. These various changes may he expressed by the 
equations : 

XII.CO /NH 2 

(1) C 5 H 4 N 4 3 + H 2 + 20 = C(< | + C0< + C0 2 

\nh.co Nra 2 

Uric acid. Parabanic acid. Urea. 

NH.00 CO.NH.CONH 2 

(2) C0< | +H 2 =| 

x XH.CO COOH 

Parabanic acid. Oxaluric acid. 

CO.XH.COXH 2 CO.OH XH 2 

(3) I + H 2 = | + C0<^ 
COOH CO.OH \NH 2 

Oxaluric acid. Oxalic acid. Urea. 

CO.OH y NH 2 

(4) C 5 H 4 X 4 3 4-3H 2 + 20=| -f 2C0< + C0 2 

CO.OH X XH 2 

Uric acid. Oxalic acid. Urea. 

Under pathological conditions, further, oxalic acid may also be 
formed in the digestive tract from the ingested carbohydrates, as a 
result of a peculiar fermentative process. This has been well 
shown by Helen Baldwin in Herter's laboratory. In some of these 
cases no free hydrochloric acid could be demonstrated in the gastric 
contents, and it was observed that inoculation of a digestive mixt- 
ure, which was originally free from oxalic acid, resulted in its ap- 
pearance if a few drops of such stomach contents were added. In 
dogs prolonged feeding with excessive quantities of glucose together 
with meat was seen to lead eventually to a state of oxaluria, which 
was associated with a mucous gastritis and the absence of free hydro- 
chloric acid. Oxalic acid could then also be demonstrated in the 
stomach content-. 

Very curiously the ingestion of quite small and npn-toxic amounts 
of oxalic acid is followed by a fairly intense indicanuria. It does 
not seem likely to me, however, that as Harnack and v. d. Leyden 
suggest, the indicanuria is here referable to a toxic action upon the 
tissue-albumins, and I am personally inclined to explain the phe- 
nomenon upon the basis of increased intestinal putrefaction. 

The amount of oxalic acid which is normally eliminated in the 
twenty-four hours fluctuates with the amount ingested, and varies 
from a few milligrammes to 2 or •'] centigrammes being usually less 
than 10 milligrammes (Baldwin). 



394 TEE URINE. 

Foods rich in oxalic acid are spinach, tomatoes, carrots, celery, 
string-beans, rhubarb, potato, dried figs, plums, strawberries, 
cocoa, tea, coffee, and pepper. Foods which contain little or no 

oxalic acid, on the other hand, are meat, milk, eggs, butter, corn- 
meal, rice, peas, asparagus, cucumbers, mushrooms, onions, lettuce, 
cauliflower, pears, peaches, grapes, melons, and wheat, rye, and oat 

flour. 

Before drawing conclusions as to the existence of abnormal 
oxaluria it is hence imperative to eliminate the possibility of an 
increased ingestion, by placing the patient upon a diet which con- 
tains little or no oxalic acid. 

An increased elimination is notably observed in association with 
various dyspeptic and nervous manifestations, and constitutes the 
condition commonly spoken of as the oxalic acid diathesis, or as 
idiopathic oxaluria. In such cases a copious deposit of calcium oxa- 
late crystals is very frequently observed. From this occurrence, 
however, it is not permissible to assume that an increased amount 
is present unless an actual quantitative estimation has been made. 
At the same time we must remember that a tendency to the de- 
position of oxalates favors the formation of gravel or calculi, 
and is hence a symptom which merits due consideration. Hot 
infrequently oxaluria of this type is associated with an increased 
elimination of uric acid and a mild grade of albuminuria, as has 
been shown by Senator, v. Xoorden, DaCosta, myself, and others. 
Whether or not the oxaluria in these cases can be explained upon 
the basis of abnormal fermentations in the gastro-intestinal tract, 
as is suggested by the observations of Baldwin, remains to be seen. 
In some this may be the case, but in others I am inclined to asso- 
ciate the oxaluria with the coexistent lithuria, and rather imagine 
that both conditions may be referable to impairment of the normal 
oxidation-processes in the liver. 

That this explanation holds good also of the apparent vicarious 
oxaluria which is at times observed in diabetes, appears quite likely. 

Properties of Oxalic Acid. — Oxalic acid occurs in the urine as 
calcium oxalate, CaC 2 4 , and is held in solution by the diacid sodium 
phosphate. It can, hence, be precipitated by diminishing the acidity 
of the urine by the addition of a little ammonia or by allowing it 
to stand exposed to the air. When allowed to crystallize out sL : ~ 
calcium oxalate occurs in the form of well -denned, strongly refrac- 
tive octahedra, iu which the principal axis of the crystals is placed 
at right angles to the plane of the microscope slide (Fig. 97). These 
are very characteristic. Other forms, however, are also quite com- 
monly observed, such as single and double dunib-bells, spheroids 
and prisms, etc. (Fig. 105). They are insoluble in ammonia and 
alcohol, almost insoluble in hot and cold water, and very slightly 
soluble in acetic acid, but dissolve with ease in the mineral acids. 



CHEMISTRY OF THE URINE. 395 

When strongly heated, the sail is decomposed into calcium oxide, 

carbon dioxide, and carbon monoxide, according to the equation 

( ■ a r,,0 4 = CaO + C0 2 -f CO. 

Tests for Oxalic Acid. — For the detection of calcium oxalate it 
is frequently only necessary to examine the sediment of the urine 
after standing for twenty-four to forty-eight hours. No oxalate 
crystals, however, may be found even when an abnormally large 
amount can be demonstrated by chemical methods. In such cases 
it is usually possible to bring about the crystallization of the salt by 
carefully neutralizing the urine with a little ammonia. Should this 
procedure not lead to the desired end, it is best to treat the urine 
with one-third its volume of 95 per cent, alcohol. The mixture is 
set aside for twenty-four to forty-eight hours, when the sediment is 

Fig. 97. 




Calcium oxalate crystals. 

centrifugal ized and examined with the microscope. This method, 
Baldwin states, represents a more delicate test for oxalic acid than 
the complicated methods of quantitative analysis which are available. 

Quantitative Estimation. — Heretofore the old method of Neu- 
bauer has been in general use, but it is at best unsatisfactory. It is 
still described at this place, as the more recent methods of Dunlop 
and Salkowski are as yet but little known. At the same time it 
must be admitted that these more modern procedures are likewise 
not free from objections, but they are nevertheless to be preferred to 
that of Xeubauer. 

Neubauer's Method. — Principle. — The calcium oxalate in the urine 
is held in solution by the diacid sodium phosphate, li' this is re- 
moved by means of calcium chloride and ammonia, the calcium 
oxalate is precipitated. By heating this strongly it is transformed 
into calcium oxide 

As 56 parts by weight of calcium oxide correspond to 128 parts 
by weight of calcium oxalate, the amount of the latter can be 
readily calculated according to. the equation : 56 : 128 : : y : x ; and 



396 THE URINE. 

x = 2.2857 y, in which y indicates the amount of calcium oxide 
found in a given amount of urine, and x the corresponding amount 
of calcium oxalate. As 1 molecule of oxalic acid, moreover, corre- 
sponds to 1 molecule of calcium oxalate, the amount of the former 
can be found from that of the latter according to the equation : 
128 : 90 : : y : x ; and x = 0.703 y, in which y represents the amount 
of calcium oxalate found, and x the amount of the corresponding 
acid. 

Method. — A large amount of urine (600 to 1000 c.c.) is thy- 
molized, so as to guard against putrefactive processes, and is treated 
with an excess of calcium chloride solution and rendered strongly 
alkaline with ammonia. The diacid sodium phosphate which holds 
the oxalic acid in solution is thus removed. The precipitate of phos- 
phates is then carefully treated with an amount of acetic acid just 
sufficient to dissolve it, without filtering. As calcium oxalate is 
almost insoluble in acetic acid, it gradually separates out. To this 
end, the mixture is allowed to stand for twenty-four hours, the 
addition of the thymol preventing the development of bacteria. At 
the end of this time the calcium oxalate is filtered off through a 
small filter. It is washed with water and treated with a small 
amount of warm hydrochloric acid, any uric acid that may have 
separated out being left behind. The filtrate is further treated with 
a small amount of very dilute ammonia, so as to render the solution 
slightly alkaline. After standing for twenty-four hours the calcium 
oxalate will have separated out, and is collected upon a smaller filter, 
the weight of the ash in this being known. After washing with 
water the contents of the filter are dried and incinerated in a cruci- 
ble, heating strongly for about twenty minutes, whereby the oxalate 
is transformed into the oxide. From the weight of this the corre- 
sponding amount of oxalic acid is readily calculated according to 
directions given above. 

Dunlop's Method (slightly modified by Baldwin). — In this case the 
calcium oxalate is precipitated from an acid solution by means of 
alcohol, instead of from an alkaline solution by calcium chloride. 
The urine is thymolized, and if alkaline acidified with a trace of 
acetic acid. 

Five hundred c.c. of a well-mixed specimen of the collected urine 
of twenty-four hours are treated with 150 c.c. of over 90 per cent, 
alcohol, to precipitate the calcium oxalate. The mixture is set aside 
for forty-eight hours. It is then filtered, care being taken to insure 
the entire removal of the crystals from the beaker. The sediment 
is thoroughly washed with hot and cold water, and finally with 
dilute acetic acid (1 per cent, solution). The filter is placed in a 
small beaker and soaked in a small amount of dilute hydrochloric 
acid. It is then washed with hot water until the washings no 
longer give an acid reaction. The acid solution and washings 



CHEMISTRY OF THE CHI Si:. 397 

are filtered, and the filtrate evaporated to about 20 c.c. This is 
treated with a very small amount of a solution of calcium chloride, 
to insure the presence of an excess of calcium. The solution is 
neutralized with ammonia, slightly acidified with acetic acid, and 
treated with strong alcohol, so that the mixture contains 50 percent. 
Alter forty-eight hours the sediment is collected on a filter free from 
mineral ash, and is washed with cold water and dilute acetic acid 
until free from chlorides. The filter with its contents is then in- 
cinerated, first over a Bunsen burner, and afterward for five minutes 
in a blow-pipe flame. On cooling over sulphuric acid the ash is 
weighed ; the result multiplied by 1.6 represents the amount of 
oxalic acid in the volume of urine examined. 

Salkowski's Method. — In the case of human urine of moderate 
concentration 500 c.c. of the non-filtered urine are evaporated to 
about one-third. On cooling, the liquid is acidified with 20 c.c. of 
hydrochloric acid (sp. gr. 1.12), and extracted three times with new 
portions of 200 c.c. each of a mixture of 9 to 10 volumes of ether 
and 1 volume of alcohol. The ethereal extracts, which contain 
the liberated oxalic acid, are carefully separated from the urine 
and filtered through a dry filter. The ether is distilled off; the re- 
maining alcoholic solution, which still contains a little ether, is placed 
in a deep evaporating-dish, diluted with 10 to 15 c.c. of water, and 
evaporated on a water-bath. The resulting milky fluid is concen- 
trated, more water being added if necessary, until it becomes clear 
and a gummy material separates out. On cooling, the liquid, which 
should measure about 20 c.c, is passed through a small filter. This 
is washed once or twice with a little water, when filtrate and washings 
are rendered slightly alkaline with ammonia, treated with 1 to 2 c.c. 
of a 10 per cent, solution of calcium chloride, and acidified with 
dilute acetic acid. The reaction should be distinctly acid, but an 
excess should be avoided. An indication that a sufficient amount 
has been added is afforded by the dissolution of the precipitate of 
phosphates, which occurs after the addition of the calcium chloride 
solution. After standing for twenty-four hours, or still better forty- 
eight hours, the calcium oxalate that has separated out is collected 
on a filter free from ash, washed with hot and cold water, dried, and 
incinerated as usual (see above). The resulting weight, multi- 
plied by 1.6 indicates the corresponding amount of oxalic acid in 
grammes. 

Literature. — P. FnrbringeT, " Zur Oxalsaureausscheidung (lurch d. Harn," 
Dentech. Arch. f. klin. Med., 1876, vol. xviii. p. 143. J. C. Dunlop, "The Elimination 
of Oxalic Acid in the Urine," etc.. Jour. Path, and Back, 1896 (an historical review 
of the subject of oxaluria is here also given). H. Baldwin. " An Experimental Study 
of Oxaluria."' Jour. Exper. Mod., vol. v. p. 27. E. Salkowski, Berlin, klin. Woch., 1900, 
p. 434; and Zeit f. physiol. (hem., vol. xxix. p. 4: > .7. E. Harnack, "Ueher Indican- 
urie in Folge von Oxalsiiurewirkung," Zeit. f. physiol. Chem., 1900, vol. xxix. p. 205. 



3.:'S THE URINE. 

ALBUMINS. 

The albumins which may be met with in the urine are serum- 
albnmin. serum-globulin, albumoses peptone- . the albumin of 
Bence Jones, haem : gl t in, uncle : -albumin, fibrin, histon, and nuel -.- - 
histon. Of these, serum-albumin is the most important from a 
clinical standpoint. 

Serum-albumin. — The question whether or not serum-albumin 
occurs normally in the urine — i. e,, under strictly physiological con- 
ditions — has been much disputed. It is claimed by some that traces 
may be temporarily met with in apparently healthy individuals after 
severe muscular exercise, cold baths, mental labor, severe emotions. 
daring menstruation, digestion, etc. This so-called physiological alhu- 
ria mostly occurs in young adults, and is usually, if not always. 
of brief duration. The urine, it is claimed, is otherwise normal — 
i. t.. of normal amount, appearance, specific gravity, and eoinp «> 
tion. and free from abnormal morphological constituents, such as 
casts, red corpuscles, leucocytes, and epithelial cells. 1 

The existence :■:' a physiological albuminuria, on the other hand. 
is denied, and the occurrence of serum-albumin at least regarded as 
pathological in every case, I have never been able to convince my- 
self of the occurrence of seram-albimiiu in the urine under strictly 
physiological conditi us, and it has been pointed out elsewhere 
that severe muscular and mental labor, severe mental emotions, 
I baths, etc.. can hardly be regarded as physiological stimuli for 
all persons. The albuminuria, so often observed during the first 

ys of life, at which time sediments of uric acid and urates, mucus, 
epithelial cells from the different portions of the urinary tract, and 
even casts may also be seen — i. cl, constituents which in adults 
wonld rigrhtlv be regarded as abnormal — has also been brought for- 
ward in support of the theory of a physiological albuminuria. 
n be no doubt, however, that this form of albuminuria is 
referable to the profound changes that take place in the circulatory 
system after birth, and to some extent perhaps also to the well- 
known uric-acid infarctions so frequently seen in the kidneys of the 
newly born, so that it would probably be better and more in accord 
with the teachings of pathology to regard this form of albuminuria 
also as abnormal. - 

The more closely the subject of the so-called physiological albu- 
minuria is studied the more improbable does its physi Logical nature 
appear, and a more detailed study of the metabolic pi sesses, it may 
be confidently asserted, will ultimately lead to the conclusion that 
the p f albumin in every cast, is a pathological phenomenon. 

The a — "oia:ion of an increased elimination of urea and uric acid 

1 C. E. Simon, " Functional Albuminuria."' N. Y. Med. Jour., 1S95. p. 330. 
: L. Landi, L'albuminuria nel parto. Morgagni, 1890, vol. xxxii. 



ALB I'M TNS. 399 

with albuminuria in apparently healthy individuals was noted twenty- 
five years ago, hut received comparatively little attention. More 
recently. Da Costa 1 has pointed out the existence of albuminuria 
associated with lithuria and oxaluria. Personal observations have 
led me to look upon this form of albuminuria as of common occur- 
rence, and while in almost every case the albumin can be caused to 
disappear from the urine by proper diet and exercise, there can be 
no doubt that, if neglected, granular atrophy may ultimately result. 

An albuminuria may at times be observed in anaemic children 
and adolescents, and particularly in masturbating boys of the mouth- 
breathing type, but can hardly be regarded as physiological. The 
same may be said of the albuminuria of pregnancy and parturition. 

The course which may be taken by these various forms of what 
should be termed functional albuminuria, in which the amount of 
albumin rarely exceeds 0.1 percent., is very interesting. The elimi- 
nation of albumin may thus be quite transitory on the one hand, as 
when following severe muscular exercise, cold baths, and the like. 
It may, however, also last for several days, or even weeks, and be 
followed by a disappearance of the albumin for a variable length of 
time, and again by its reappearance and continuance for days and 
weeks. The term intermittent albuminuria 2 has been applied to this 
latter type. At times the albuminuria may follow a definite course, 
disappearing and reappearing with such regularity that it has not 
improperly been styled cyclic albuminuria? In this form the albu- 
min generally disappears from the urine during the night or during 
prolonged rest in bed, and reappears during the day, the erect 
posture apparently favoring its reappearance ; the term postural or 
orthostatic albuminuria has hence also been suggested for this form. 
Oswald, who made a careful study of cyclic albuminuria in Biegel's 
clinic, regards its occurrence as distinctly pathological, and as indi- 
cating the existence of nephritis. Remembering the importance of 
the subject, it may not be out of place to enumerate the reasons 
which led Oswald 4 to this conclusion : 

1. The patients generally come to the physician complaining of 
certain definite symptoms which are similar to those noted in cases 
of true nephritis. At times, however, no complaints are made, be- 
cause the patients have reasons for concealing them (as in examina- 
tions for life-insurance), or because they are temporarily absent. 

2. The subjective complaints, as well as the anaemia so frequently 
observed in such cases, generally disappear, together with the albu- 

1 Da Costa. "The Albuminuria and Bright' s Disease of Uric Acid and Oxalic 
Acid.' - Am. Jour. Med. Sci., 1895. 

2 Bull, Berlin, klin. Woeh., 1886, vol. xxiii. p. 717. Mareau. Rev. de med., lss(i, 
vol. vi. p. 855. Klcmperer, Zeit. f. klin. Med., 1887, vol. xii. p. 168. 

3 A. Keller. Beitriige z. Kenntniss d. cyklischen All>uminurie. Diss.. Breslau. 1896. 
* K. Oswald, "Cyklische Albuminurieu. Nephritis," Zeit. f. klin. Med., vol. xxvii. 

p. 73. 



400 THE URINE. 

min, under suitable treatment, and reappear when the anaemia again 
becomes marked. 

3. In many, a history of an antecedent nephritis the result of 
scarlatina or diphtheria may be obtained, as in three cases of Heub- 
ner, in fourteen cases out of twenty described by Johnson, etc. In 
some also a direct transition from an acute nephritis to the cyclic 
form of albuminuria has been noted. TVhere this was not possible 
the history of an acute infectious disease or an angina that had been 
overlooked in the clinical history must be regarded as a possible cause. 

4. The absence of morphological elements, especially tube-cast-, 
does not exclude a nephritis. A large number of cases, moreover, 
have recently been observed in which casts were repeatedly found. 

5. A cyclic albuminuria may be observed in many jases : 
chronic nephritis. 

6. Marked organic abnormalities (such a- heart -lesions ) need not 
be demonstrable, as they may be absent for a loug period of time or 
may be unrecognizable. 

Senator's 1 statement, that the existence of a physiological albu- 
minuria is proved by the fact that the morphological constituent- : 
the primitive nubecula contain albumin, requires no further criticism. 
and should be regarded as a misconstruction of the main point at 
issue — a mere sophism ; and Posner's 2 observations, in view of the 
researches of Malfatti, 3 which tend to show that the body obtained 
by Posner was not serum-albumin, but a nucleo-albumin. may now 
be regarded as erroneous. 

In conclusion, it may be safely asserted that a transitory , intermit- 
tent, and cyclic albuminuria is not infrequently observed in apparently 
healthy individuals, but that the facts so far brought forward do not 
warrant the assumption that such forms of albuminuria are physio- 
logical* 

It would lead too far to enter into a detailed consideration of the 
various causes that have from time to time been suggested as an ex- 
planation of the fact that albumin does not occur in the urine under 
normal conditions. There can be no doubt, however, that the integ- 
rity of the epithelial lining of the glomeruli and the convoluted 
tubules must be regarded as the principal factor which prevents the 
albumin of the blood from passing into the urine. When the readi- 
ness with which the glandular structures of the kidney respond to 
any abnormal stimulation is considered, it is easily understood how 
an albuminuria may be produced in many different ways. Aside 

1 Senator. Die Albuminurie. Hirschwald. Berlin. 1882 

2 C. Posner. Berlin, klin. Woch.. 1885, vol. xxii. p. 654 ; Virchow's Archiv. 188G 
vol. civ. p. 497 : Arch. f. Auat. u. Physiol.. 1888 

3 Malfatti. Internat. Ceutralbl. f. d. Phvsiol. u. Pathol, d. Ham- n. Sexnalorsane. 
1S39, vol. i. p. 266. 

4 v. Xoorden. Deutsch. Arch. f. klin. Med., vol. xxxviii. pp. 3 and 205. Leute. 
Zeit. f. klin. Med.. 1887, vol. xiii. p. 1. Winternitz. Zeit. f. phvsiol. Cheni.. 1591. vol. 
xv. p. 189. C. E. Simon, loc. cit, 



ALBUMINS. 401 

from acute and chronic inflammatory processes in the widest sense 
of the word, an albuminuria may be the result of circulatory dis- 
turbances in the kidneys of whatever kind — i. c, the result of 
anaemia as well as oi' hyperemia. In many and perhaps the 
majority oi' eases in which what Bamberger ' terms a hazmatogenous 
albuminuria occurs, we have direct evidence of the existence of cir- 
culatory disturbances, as in cases of uncompensated valvular lesions, 
weak heart, emphysema, hepatic cirrhosis, etc. In other cases, how- 
ever, the existence of such disturbance can only be surmised, and the 
question, whether or not the albuminuria observed in the various 
infectious diseases, for example, is referable to circulatory abnormali- 
ties or to a direct irritative action of microbic poisons upon the 
renal parenchyma, must still remain open. 

From personal studies in connection with the functional albu- 
minuria of Da Costa, it seems not unlikely that in many cases in 
which obscure circulatory disturbances are supposed to exist and are 
held responsible for an existing albuminuria, this is referable rather 
to the strain thrown upon the kidneys by the continued elimination 
of abnormally large quantities of organic material, the quantity of 
water being at the same time proportionately small. 

If it is remembered, furthermore, that injuries affecting certain 
portions of the brain are followed by albuminuria, and that this 
may be artificially produced by a piqure, analogous to the glucosuric 
pigure of C. Bernard, still another factor is given which may pos- 
sibly enter into the causation of albuminuria. 

Obstruction to the outflow of urine from the kidneys has also 
been experimentally shown to lead to albuminuria, an observation 
with which clinical experience is in perfect accord. 

Finally, an abnormal composition of the blood may at times cause 
the albuminuria. 

In passing on to a more detailed study of the various pathological 
conditions in which an elimination of albumin may be noted, an 
attempt will be made to classify the various forms of albuminuria 
in accordance with the more general considerations set forth above. 
It should be remembered, however, as already indicated, that it may 
be very difficult, if not impossible, to assign one single cause to 
a given clinical case, as several factors may at the same time be 
operative in the production of the albuminuria. 

1. FUNCTIONAL ALBUMINURIA — Under this heading may be 
comprised the various forms of "physiological " albuminuria, which 
have already been considered. 

2. The albuminuria associated with organic dibeases 
OF the kidneys, viz., acute and chronic nephritis, renal arterio- 
sclerosis, amyloid degeneration of the kidney s.- 

In acute nephritis, albuminuria, usually of great intensity, is a 
1 v. Bamberger, Wien. rued. Woch., 1881, pp. 145 and 177. 2 Senator, loc. cit. 

26 



402 THE URINE. 

constant and most important symptom. The amount eliminated 
is generally proportionate to the intensity of the disease, but varies 
within fairly wide limits, generally from 0.3 to 1 per cent., corre- 
sponding to a daily excretion of from 5 to 8 grammes. Much larger 
quantities, it is true, are at times excreted, but it may be definitely 
stated that the daily loss of albumin seldom exceeds 20 grammes. 

In chronic parenchymatous nephritis the elimination of albumin 
is likewise constant, and the amount excreted in severe cases may 
even exceed that observed in the acute form. An elimination of 
from 15 to 30 grammes, viz., 1.5 to 3 per cent, by weight, is 
frequently observed. 

In the ordinary form of chronic interstitial nephritis the elimina- 
tion of albumin is, as a general rule, slight, and rarely amounts to 
more than 2 to 5 grammes pro die. At the same time it is not 
unusual to meet with an apparent absence of albumin if the more 
common tests (see below) are employed. If it is remembered that 
very often the diagnosis of the disease is dependent upon the demon- 
stration of the presence or absence of albumin, the necessity of fre- 
quent examinations and the employment of more delicate tests, par- 
ticularly of the trichloracetic acid test, as well as of a microscopical 
examination, is at once apparent. This is even of greater impor- 
tance in the renal arteriosclerosis of Senator, in which albumin by 
the ordinary tests is probably not demonstrable in the majority of 
cases, and in which even the trichloracetic acid test may not be of 
service, and casts are absent. 

Amyloid degeneration of the kidneys, in the absence of inflamma- 
tory processes, is accompanied by a condition of the urine closely 
resembling that observed in the ordinary form of chronic interstitial 
nephritis. A total absence of albumin, however, is less frequentlv 
noted, while an amount varying between 1 and 2 per cent, is not 
uncommon. It will be shown later on that in this condition con- 
siderable amounts of serum-globulin are excreted in addition to 
the serum-albumin ; larger amounts, in fact, than are generally 
observed in this form of chronic renal disease, so that Senator sug- 
gests that such a relation, in the absence of an acute nephritis, or 
an acute exacerbation of a chronic nephritis, may be of a certain 
diagnostic value. 

3. Febrile Albuminuria. 1 — That albuminuria may occur in 
almost any one of the various febrile diseases is a well-known fact, 
but it is important to remember that, while such an albuminuria 
may at times be referable to a true nephritis developing in the course 
of or during convalescence from an acute febrile disease, such is the 
exception, and not the rule. Under this heading, only that form 
will be considered which is not associated with distinct changes 

1 Levden, Zeit. f. klin. Med., 1881, vol. iii. p. 161. H. Lorenz. Wien. klin. Woch.. 
1888, vol. i. p. 119. 



ALBUMINS. 403 



Qff 



affecting the renal parenchyma, and which generally appears duri 
the height of the disease only, and disappears with a return of the 
temperature to normal. As has been mentioned, it is often 
difficult, it' not impossible, to assign a definite cause for an albu- 
minuria of this character, and in all probability several factors are 
in operation at the same time. In the beginning of the disease, 
when the blood-pressure, as a rule, is increased, the albuminuria 
may be referable to an iseluemia of the kidneys, as the increased 
pressure in fever, according to Cohnheim and Mendelson, is largely 
referable to spasm of the arterioles. Later on, or in the begin- 
ning of eases in which especially severe intoxication exists, the 
blood-pressure may be subnormal, and the albuminuria be due to 
this cause — i. e., a hypersonic condition of the kidneys. As a mat- 
ter of fact, it has been experimentally demonstrated that both ansemia 
and hyperemia of the kidney structure may lead to albuminuria. 
On the other hand, it is not unlikely that the strain thrown 
upon the kidneys by an excessive elimination of organic material, 
in the absence of a correspondingly large quantity of water, may 
produce albuminuria. I have repeatedly seen the functional 
albuminuria of the type described by Da Costa disappear during 
the administration of a diet relatively poor in nitrogen, while an 
increased diuresis was at the same time effected by the consumption 
of large amounts of water. 

In those grave cases of typhoid fever, furthermore, which are 
characterized by high fever and pronounced nervous symptoms it 
would appear quite likely that the albuminuria, which in these cases 
is particularly marked, is referable to a direct influence upon the 
central nervous system, and in some cases, at least, also dependent 
upon an irritant action upon the renal epithelium on the part of the 
microbic poisons circulating in the blood. The character of the albu- 
minuria will largely depend upon the intensity of the intoxication ; 
in other words, upon the amount of bacterial poison present at any 
one time in the blood. 

Notwithstanding statements to the contrary, albuminuria may be 
regarded as a constant symptom of typhoid fever, as has been defi- 
nitely demonstrated by Gubler and Robin. It is difficult to say why 
other observers have found albumin in only a comparatively small 
percentage of cases, but it is not unlikely that this is owing to a lack 
of uniformity in methods, it being presupposed also that questions 
of this kind can only be decided by daily examinations. According 
to Robin, the trace of albumin which is at time- observed during 
the first week of the disease is an albumose, while later on serum- 
albumin is constantly found; the amount increases with the inten- 
sity of the morbid process, and the highest figures are reached in fatal 
cases. The more severe the disease the earlier does albumin appear 
in the urine, it being remembered, however, that reference is had 



401 THE URINE. 

only to those cases in which distinct renal changes are not demon- 
strable. Toward the termination of the fastighun the amount of 
albumin generally undergoes a certain diminution, and may even 
disappear entirely. This diminution, however, is only temporary, 
and in severe cases the albumin again increases in amount during 
the period of great variations in the temperature. In light cases 
an increased elimination also takes place at this stage, but is soon 
followed by a decrease, after which only traces can .be demonstrated. 
In some cases it disappears entirely, but it is rare, according to Robin, 
to meet with cases in which at least a trace does not reappear during 
convalescence. 

In light cases the albuminuria rarely persists longer than the fifth 
or eighth day of convalescence, and Robin even goes so far as to say 
that a relapse may be anticipated if the albuminuria does not disap- 
pear at that time. A limited number of personal observations have 
borne out the correctness of this view, and in one case in which a 
relapse occurred so late as the fifteenth day of convalescence traces 
of albumin could be demonstrated during the entire period. In 
severe cases, on the other hand, the albumin persists for a variable 
length of time, and rarely disappears before the tenth day of con- 
valescence. At times an increase is seen during convalescence when 
traces only have previously been observed. It is this form which 
the French generally speak of as colliquative albuminuria. While 
this is principally observed in typhoid fever, it is not unusual 
to meet with it during convalescence from various other acute 
diseases. Care must be taken not to confound the albuminuria so 
frequently seen during convalescence from typhoid fever, referable 
to a pyelitis, with the form just described. 

From the following summary, constructed from data given in 
Robin's l monograph on the urine of typhoid fever and other acute 
infectious diseases which may be associated Avith a typhoid condition, 
an idea may be formed of the occurrence of albuminuria, as well as 
of its degree of intensity in these diseases : 

Acute miliary tuberculosis : albumin is much less frequent than 
in typhoid fever ; when present, it is rarely found in the abundance 
so characteristic of the fatal cases of the latter disease. 

Pneumonia : albumin is as uniformly present as in typhoid fever, 
and at times very abundant. 

Grippe : albumin is infrequent ; present in about 20 per cent, of 
the cases, and only in traces. 

Herpetic fever : albumin never present in large amounts. 

Embarras gastrique : albumin rarely present. 

Adynamic enteritis of adults : albumin almost always present, but 
usually only in traces. 

Cerebrospinal meningitis : albumin in fairly large amounts. 
1 A. Robin, Urologie clinique de la fievre typhoide, Paris, 1877. 



ALBUMINS. 406 

Vegetative endocarditis ■ albumin very abundant in about 14 per 
cent., evident in 44 per cent., and traces in 42 per cent, of all eases. 

Aeute articular rheumatism : albumin present in about 40 per 
cent. 

Rubeola : albumin usually absent in light cases, but present in 
the more severe and complicated forms. 

Intermittent fever : albumin variable. 

In conclusion, it may be said that practically every acute febrile 
disease, even simple follicular tonsillitis, may be accompanied by 
albuminuria in the absence of definite changes affecting the renal 
parenchyma. Its occurrence in an individual case is probably 
dependent to a very large degree upon the intensity of the intoxica- 
tion. AVhile it is generally an easy matter to distinguish between 
this form of albuminuria and that associated with distinct organic 
changes in the kidneys, considerable difficulty may at times be 
experienced ; this question will be dealt with later on. 

4. Albuminuria referable to Circulatory Disturbances. 1 
— To this class belongs the albuminuria so frequently observed in 
cardiac insufficiency referable to valvular lesions, degeneration of the 
heart-muscle from whatever cause, disease of the coronary arteries, 
etc., as well as in cases of impeded pulmonary circulation affecting 
the general circulation through the right heart, and, finally, in con- 
ditions associated with local circulatory disturbances, such as com- 
pression of the renal veins by a pregnant uterus, tumors, etc. It 
has been pointed out that febrile albuminuria also may, to a certain 
extent at least, be referable to such causes — i. c, an ischsemia or 
hypersemia of the kidneys produced by an increased or diminished 
blood-pressure. The albuminuria observed in cases of cholera 
infantum, the simpler forms of intestinal catarrh, and in cholera 
Asiatica particularly, are undoubtedly dependent upon such causes. 
The occurrence of albuminuria after cold baths, as stated above, is 
regarded by many as a " physiological " phenomenon ; but this view 
should be rejected, as there can be little doubt that this form is also 
referable to circulatory disturbances. The quantity of albumin 
found under these circumstances varies considerably, but rarely 
exceeds 0.1-0.2 per cent, unless the disease has advanced to a stage 
where distinct changes in the renal parenchyma have resulted. 

5. AXBTJMINUKLA REFERABLE TO AN IMPEDED OUTFLOW OF 

Urine. — Clinically, albuminuria referable primarily to an impeded 
outflow of urine from the kidneys i- probably of more frequent 
occurrence than is generally supposed, and especially in women, in 
whom Kelly and others have demonstrated the frequenl existence 
of ureteral stenoses. A complete blocking of the excretory duel, 
on the other hand, is rarely seen, but may be caused by the impac- 
tion of a renal calculus, the pressure of a tumor, or 1'ollowing cer- 

1 Senator, loe. cit. 



406 THE URINE. 

tain gynaecological operations in which the ureter is accidentally 
caught in a suture, etc. It has also been suggested that the albu- 
minuria of pregnancy may be due to compression of a ureter, but 
it is more likely that other factors are here at play, such as com- 
pression of the renal arteries and veins. 

6. Axbumestueia of ELemic Origin. 1 — It was formerly sup- 
posed that Bright' s disease Avas dependent upon certain abnormalities 
of the blood, and as a matter of fact this view has not only never 
been disproved, but is actually gaining ground from day to day. 
According to Semmola, Bright' s disease is primarily due to an 
abnormal power of diffusion on the part of the albumins of the 
blood, which are eliminated by the kidneys as waste material. As 
a result of the excessive amount of work thus done definite renal 
changes are finally produced. According to his theory, then, the 
albuminuria is the primary factor in the causation of nephritis. 
Should this hypothesis hold good, Senator is correct in asserting that 
an albuminuria of functional origin, so to speak, must precede the 
occurrence of the nephritis proper. He, however, doubts the occur- 
rence of a prenephritic albuminuria ; but others have noted the occur- 
rence of definite renal changes which manifestly followed an appar- 
ently functional albuminuria (Da Costa J. Further researches in this 
direction are urgently needel, and Semruola's view can at present only 
be regarded as an hypothesis. But even if such blood-changes as 
those which Semmola suggests should not exist, there can be little doubt 
that true nephritis is dependent upon an acute or chronic dyscrasia 
of the blood, either in the sense of an abnormal mixture of the nor- 
mal elements or of the presence of abnormal constituents, and not- 
ably of poisons. The same considerations undoubtedlv also apply 
to various other forms of albuminuria, in so far as these are not the 
direct result of circulatory disturbances. 

Clinically, albuminuria of haemic origin is observed in various 
diseases of the blood, such as purpura, scurvy, leukaemia, pernicious 
anaemia, as also in cases of poisoning with lead and mercury, in 
syphilis, jaundice, diabetes, following the inhalation of ether and 
chloroform, etc. The albuminuria associated with an excessive 
elimination of uric acid and oxalic acid, and, according to personal 
observations, with an excessive elimination of organic material in 
general, notably of urea, probably also belongs to this class. 

7. Toxic Albuminuria. — It has already been stated that the 
albuminuria of acute febrile diseases mav. to a certain extent, be 
referable to a direct irritant action on the part of bacterial poisons 
upon the renal parenchyma. Poisoning with cantharides, mustard, 
oil of turpentine, potassium nitrate, carbolic acid, salicylic acid, tar, 
iodine, petroleum, phosphorus, arsenic, lead, antimony, alcohol, and 
mineral acids produces albuminuria. . In all probability, however, 

1 v. Bamberger, loc. cit. 



ALBUMINS. 407 

the albuminuria here observed is referable not only to a direct irri- 
tant action upon the glandular epithelium of the kidneys, but also 
to circulatory disturbances. 

8. Neurotic Albuminuria. — It is claimed by some that albu- 
min, usually in small amounts, is eliminated in epilepsy alter every 
attack, while others either deny its occurrence under such conditions 
or regard it as exceptional. In a number of cases in which I had 
occasion to examine urine voided alter an attack albumin was usually 
absent. It should be stated, however, that the seizures in these 
cases were comparatively slight, and that unfortunately an exam- 
ination for semen was not made in those urines in which traces of 
albumin were demonstrated. An examination of the urine voided by 
a patient, after having been in the epileptic state for more than forty- 
eight hours, showed the presence of a small amount of albumin 
associated with an enormous elimination of uric acid, as well as a 
large excess of urea. Semen was absent. 1 

A transient albuminuria has also been noted in cases of progressive 
paralysis, mania, tetanus, delirium tremens, apoplexy, migraine, 
Basedow's disease, brain tumor, etc. 

Although albuminuria may apparently be produced artificially by 
injuries affecting a certain area in the floor of the fourth ventricle, 
analogous to the production of glucosuria (see Glucosuria), it would 
probably be going too far to assume the existence of a certain spe- 
cific centre, stimulation of which causes the appearance of albumin 
in the urine. While the influence of the nervous system in prevent- 
ing the passage of albumin through the glomeruli under normal 
conditions i< undoubted, it would appear more likely that the albu- 
minuria following injuries to the central nervous system is referable 
to circulatory disturbances in the kidneys secondary to lesions of 
the brain, and especially of the medulla. The albuminuria observed 
in certain neurotic individuals, on the other hand, is probably more fre- 
quently associated with metabolic abnormalities, and is of haemic origin. 

9. A DIGESTIVE ALBUMINURIA has also been described, but need 
not be considered in detail. Suffice it to say that it may follow the 
ingestion of excessive amounts of cheese, eggs — particularly when 
taken raw — beef, etc I have seen albuminuria follow free indul- 
gence in root beer. It is. of course, difficult to explain such oc- 
currences ; but bearing in mind the fact that albuminuria very 
often follows the ingestion of such articles almost immediately, 
and before they have become absorbed, it is hardly justifiable 
to refer this form to the existence of a hyperalbuminosis. It 
would appear more rational, as Senator has suggested, to think of 
reflex vasomotor or trophic changes affecting the kidneys ; while in 
other cases, in which the albuminuria does DOi follow the ingestion 
of such articles of food immediately, it is quite probable that this 

1 M. Huppert, Virehow's Archiv, 1-7 1, vol. lix. p. 305. 



408 THE URINE. 

may be dependent upon certain metabolic abnormalities affecting the 
normal composition of the blood. 1 

In the account thus given of the occurrence of albuminuria and 
its possible causes, reference has been had to only a purely renal albu- 
minuria. It should be remembered, however, that the origin of the 
albumin may often be extremely difficult to determine, as albuminous 
material, such as blood and pus, may become mixed beyond the 
glandular portion of the kidneys with what would otherwise have 
been a perfectly normal urine, and that such an admixture may take 
place not only in the ureters, the bladder, and the urethra, but even 
in the pelvis of the kidney. 

The term accidental albuminuria is applied to a condition in which 
albuminous material becomes mixed with a urine beyond the kidneys, 
as in cases of cystitis and urethritis, or whenever semen has entered 
th3 urine while the renal urine proper is free from albumin. An ad- 
mixture of pus, blood, lymph, or chyle may, however, also occur in the 
kidneys, when the albuminuria is termed accidental renal albuminuria, 
an example of which is frequently seen in the slight degree of albu- 
minuria referable to pyelitis during convalescence from typhoid 
fever. By a mixed albuminuria and a mixed renal albuminuria, on 
the other hand, we are to understand conditions in which the source 
of the albumin is twofold, renal and extrarenal in the first instance, 
parenchymal and extraparenchymal in the second, examples being the 
albuminuria of cystitis combined with nephritis and pyelonephritis, 
respectively. 

It is manifest, of course, that in every instance in which albumin 
is found in th3 urine its origin should be ascertained. While this 
question is usually readily decided by a microscopieal examination 
of the urine, considerable difficulty may occasionally be experienced. 
It is a well-known fact that in the urine of women a trace of albu- 
min may frequently be detected, which is not due to any lesion of 
the urinary organs, but to an admixture of vaginal discharge, of 
blood during the process of menstruation, and, in married women, 
of semen. Whenever, therefore, doubt is felt as to the origin of the 
albumin, the specimen for examination should be obtained by the 
catheter, care being taken previously to cleanse the vulva. In men 
albumin may be referable to a gonorrhoeal urethritis. In such cases 
it is well to let the patient flush out his urethra first, and to make 
use for examination of the portion last voided. Very often, how- 
ever, the conditions are more complex, it being uncertain whether 
the albumin is referable to the presence of pus only, or whether its 
origin is in the renal parenchyma. In such cases, as in cystitis, 
pyelonephritis, etc., a careful microscopical examination and enumer- 
ation of the pus-corpuscles with the Thoma-Zeiss instrument are 

1 The albumin which is eliminated after the ingestion of much egg-albumin, how- 
ever, does not belong to this category. 



ALBUMINS. 409 

called for, and will in the majority of instances decide the question. 
Generally speaking, the amount of albumin found in uncomplicated 

cases of cystitis does not exceed 0.15 per cent., while in cases of 
pyelitis of the same intensity the amount of albumin is from two to 
three times as la rue. 

Of late, attention has repeatedly been drawn to the occasional 
presence in the urine of an albuminous body which is soluble in 
aeetie acid, and which Patein regards as a modification of common 
serum-albumin. It has thus far been observed in only eight eases, 
viz., twice in chronic nephritis, three times in eclampsia, once in a 
cystic kidney, once in tonsillitis following an injection of diphtheria 
antitoxin, and once in a pregnant woman in whom typhoid fever 
developed. I should suggest that the substance be spoken of as 
Patau** album in l until its chemical identity has been established. 
The term acetosoluble albumin is, of course, likewise admissible. 

So far as the amount of albumin which may be eliminated in the 
twenty-four hours is concerned, an excretion of less than 2 grammes 
may be regarded as insignificant, 6 to 8 grammes as a moderate 
amount, and 10 to 12 grammes or more as excessive. An excretion 
of 20 to 30 grammes is exceptional. 

Serum-globulin. — It has been pointed out that in cases of amyloid 
degeneration of the kidneys serum -globulin is found in the urine 
together with serum-albumin in large amounts, and, according to 
Senator, a ratio between the two albumins of 1 : 0.8 : 1.4 may be 
regarded as a fairly constant symptom of the disease, and is of diag- 
nostic importance. There seems to be no doubt, however, that 
serum-globulin occurs in the urine, although in much smaller quan- 
tities than in the disease mentioned, whenever serum-albumin is 
eliminated. 2 

A most remarkable instance of globulinuria has been recorded 
by Xoel Paton, 3 in which the globulin separated out in crystalline 
form and was found in extraordinarily large quantity, amounting 
on one day to 70 grammes. 

Albumoses. — Albumoses have frequently been encountered in 
the urine, but are probably more frequently overlooked, as the bodies 
in question are not precipitated on boiling. In former years they 
were commonly regarded as peptones. At present, however, it 
appears to be a well-established fact that true peptones, in the sense 
of Kuhne, viz., true albumins which are not precipitated by salting 
with ammonium sulphate, do not occur in the urine, and the term 
peptonuria should accordingly be abandoned. 

1 Patein. " Aceto-solnble Albumin in the Urine," Compt. rend. <le I' Acad, des Sci., 
1889. Coplin, Phila. Med. Jour., 1899, p. 957. 

- Edlefsen, Deutsch. Arch. f. klin. Med., vol. vii. p. 67. Senator, Virchow's Archiv, 
vol.lx. p. 476. Petri, Diss., Berlin, 1-?*;. 

3 B. Bramwell and X. Paton, Laboratory Reports of the Royal College of Physicians, 
Edinburgh, 1892, vol. iv. p. 47. 



410 THE URINE. 

Albumosuria is observed under a great variety of conditions. 
It is thus noted in association with large accumulations of pus 
within the body, and there can be little doubt that the albumo- 
suria is in such instances referable to a disintegration of the pus- 
corpuscles and a resorption of the resulting albumoses. This form 
has hence been termed pyogenic albumosuria. A hepatogenic form 
is noted in connection with diseases of the liver, notably acute 
yellow atrophy. Of its origin, however, nothing is known. For- 
merly, when the condition was looked upon as a peptonuria, and 
when it was thought that peptones were retransformed into native 
albumins in the liver, the " peptonuria " was explained upon the 
assumption that the liver had lost this power, and that the "peptones " 
accumulated in the blood, and were consequently eliminated in 
the urine. Later researches showed that the transformation of 
peptones into albumins takes place in the intestinal mucous 
membrane, and that the liver probably has no part in the process 
whatsoever. The explanation given had therefore to be aban- 
doned, and, as I have just indicated, we know nothing whatever 
of the origin of this hepatic albumosuria. Possibly it is of an 
enzymatic nature. 

An enterogenic form of albumosuria has been noted in various 
diseases of the intestinal tract, such as typhoid fever, tubercular 
ulceration, carcinoma, etc.; and it is possible that in these cases the 
albumoses are either directly absorbed from disintegrating pus, or 
that the intestine perhaps has in part lost the power of preventing 
the resorption of albumoses as such into the blood. 

A histogenic or hematogenic origin has been ascribed to the albu- 
mosuria which is seen in cases of scurvy, in dermatitis, in various 
forms of poisoning, during the puerperal period and pregnancy, par- 
ticularly following death of the foetus, in various psychoses, etc. 

A renal or vesical form of albumosuria is further noted in which 
the albumoses are derived from contained albumins, owing either to 
the presence of the common proteolytic ferments of the urine or to 
bacterial action, as in decomposing albuminous urines. 

Aside from the conditions already mentioned, albumosuria has 
been observed in various infectious diseases, such as septicaemia, 
pyaemia, diphtheria, measles, scarlatina, phthisis ; further, in associ- 
ation with leukaemia, nephritis, puerperal parametritis, endocarditis, 
caries, pleurisy, heart-disease, apoplexy, myxoedema, carcinomatous 
peritonitis, pneumonia, liver abscess, etc. 

In the differential diagnosis of suppurative meningitis a positive 
peptone-reaction in the older sense of the word, according to Senator, 
speaks strongly in favor of the existence of this disease. In sup- 
port of this view he cites the case of a young man, the subject of a 
median otitis of long standing, in which symptoms pointing to a 
meningitis — viz., fever, headache, and pains in the neck — were 



ALBUMINS. 411 

present, but in which no " peptonuria " was found to exist, and in 
which an operation revealed the presence of a cholesteatoma. 

A digestive form of albumosuria lias recently been described, in 
which albumoses appear in the urine alter their ingestion in large 
quantities, and it is claimed that this is observed only in cases of 
ulcerative disease of the intestinal tract. Only a positive result, 
however, is of value. 

Very frequently albumosuria accompanies albuminuria, a condi- 
tion which Senator has termed mixed albuminuria, and it is interest- 
ing to note that the albumosuria may alternate with the albuminuria, 
and may precede or follow the latter, hi any case in which albu- 
moses can be demonstrated in the nrine the appearance of albumin 
should accordingly be anticipated. 

Literature.— Hofmeister, Prag. med. Woch., 1S89, vol. v. pp. 321 and 325. 
v. Noorden, I.ehrbuch d. Path. d. Stoffwechsels, Hirschwald, Berlin, 1893, p. 215. 
Senator, Deutsch. med. Woch., 1895, vol. xxi. p. 217. Stadelmann, Untersuchungen 
fiber Peptonurie, Bergmann, Wiesbaden. Is94. v. Jaksch. Prag. med. Woch., vol. v. 
pp. 292 and 303, and vol. vi. pp. 61, 74, 86, 133, 143; Zeit. f. klin. Med.. 1883. vol. vi. 
p. 413. Krehl u. Matthes, Arch. f. klin. Med.. 1895, vol. slv. p. 54. Maixner, Zeit. f. 
klin. Med., 1SS4. vol. viii. p. 234. Fisehel. Arch. f. Gynaek., 1884, vol. xxiv. p. 27. 
v. Jaksch, Prag. med. Woch., 1895, vol. xx. p. 430. Katz. Wien. med. Blatter, 1890, 
vol. xiv. L. v. Aldor, Berlin, klin. Woch., 1899, pp. 765 and 785. 

Bence Jones' Albumin. — In association with the occurrence of 
multiple myeloma of the bones, notably when affecting the thora- 
cic skeleton, a peculiar albuminous body is found in the urine, 
whieh is apparently pathognomonic of the disease in question. It 
was first observed by Bence Jones, and has heretofore been regarded 
as an albumose. From the researches of Magnus Levy and my 
own investigations, however, it appears that the substance is in 
reality a true albumin, as it yields a proto-albumose on peptic diges- 
tion ; but it differs from all known albumins in its relative solu- 
bility on boiling, and in the readiness with which it dissolves in 
dilute ammonia after precipitation with alcohol. Like casein, it 
contains no hetero-group, but is distinguished from it by the pres- 
ence of a carbohydrate radicle and the probable absence of phos- 
phorus. It is orystallizable, and may occur in the urinary sediment 
in the form of typical spheroliths. 

The amount of the substance which may be found in the urine is 
variable. Some observers have noted an elimination of from 0.25 
to 6.0 pro mille, while others report much larger quantities. In 
Bence Jones' case the elimination rose on-one occasion to 6.7 per 
cent., corresponding to a total output of 70 grammes in the twenty- 
four hours — i. r., to nearly as much as the entire amount of the 
albumins of the blood-plasma. 

As regards the origin of the albumin, nothing definite i< known, 
but there is reason to suppose that it is not derived from the myel- 
omatous tissue as such. We may imagine, however, that through 



412 THE URINE. 

the agency of the cells of the abnormal tissue, viz., their products 
of metabolism, the normal transformation of the ingested albumins 
into tissue-albumins is impeded, resulting in the production of the 
substance in question, which is then eliminated as foreign matter. 

The disease seems to be comparatively rare, and thus far only 
seventeen cases have been reported in which due attention has been 
paid to the condition of the urine. Besides these there are a few 
additional cases in which no special note has been made of this 
point, though Zahn states that in his case u sometimes more and 
sometimes less albumin n was found. Runeberg also reports that 
the urine of his patient contained much albumin, while the kidneys 
were found practically normal at autopsy. 

As the diagnosis of the disease, in its early stages at least, is 
altogether dependent upon the demonstration of the albumin in 
question, a special examination should be made in this direction in 
all cases of obscure bone-pain, as also in obscure cases of ansemia, 
since Ellinger has shown that at times the disease may take its 
course without the occurrence of local symptoms, while a marked 
anaemia may exist. 

Of special interest in this connection is the fact that Ziilzer claims 
to have succeeded in bringing about the appearance of Bence Jones' 
albumin in the urine of animals by feeding with pyrodin, which is 
known to be a distinct hemolytic poison. 

Liteeatuee. — Bence Jones. Med. and Chir. Trans.. 1850. vol. xxxiii. : and Phil. 
Trans. Koval Soc. of London, 1548. Kiihne, " Ueber Hemialbuuaose im Ham,'' Zeit. 
f. Biol., vol. xxix. p. 209. Ellinger, " Ueber d. Vorkommen d. Bence Jones* sehen 
Korper ini Ham." Arch. f. klin. Med.. 1896, vol. Isii. p. 255. Magnus Levy. Zeit. f. 
phvsiol. Chem.. 1900, vol. xxx. p. 200. Hamburger, Johns Hopkins Hosp. Bull., Feb., 
1901. Ziilzer, Berlin, klin. Woch.. 1900, p. 891. 

Haemoglobin (Methsemoglobin). — Under normal conditions the 
disintegration of the red blood-corpuscles which is constantly taking 
place in the body never results in such a degree of hemoglobinemia 
as to be followed by an elimination of haemoglobin in the urine. 
Whenever the destruction of red corpuscles is so extensive, how- 
ever, that the liver is unable to transform into bilirubin all the 
blood-coloring matter set free, kcemoglobinuria occurs. While these 
factors, then — i. e., an excessive destruction of the red blood-cor- 
puscles and an insufficiency on the part of the liver — must be 
regarded as explaining every case of hemoglobinuria, our knowledge 
of the ultimate causes of such excessive disintegration, as well as 
the manner in which these operate, is limited. Formerly the term 
hiematinuria was applied to this condition. It was shown, however, 
that the pigment eliminated is in reality not hematin. but usually 
methemoglobin, and only at times haemoglobin, so that the term 
hemoglobinuria is also ill chosen. 

Most common is the hemoglobinuria produced by certain poisons, 
such as potassium chlorate, arsenious hydride, hydrogen sulphide, 



ALBUMINS. 413 

pyrogallic acid, naphtol, hydrochloric acid, tincture of iodine, carbolic 
acid, carbon monoxide, etc., and also by morels (Helvella esculenta). 

Quite familiar is the hemoglobinuria observed following trans- 
fusion of the blood of animals into man, such as that of the call" 
and lamb ; also the form seen in extensive burns and in insolation. 

While hemoglobinuria may occur in the course of any one of the 
specific infectious diseases, such as scarlatina, icterus gravis, variola 
hemorrhagica, typhoid fever, yellow fever, etc., it is said to be espe- 
cially frequent in cases of malarial intoxication. This view is not 
accepted by many ; Osier, among others, believes that it has fre- 
quently been confounded with malarial hematuria. I have never 
seen an instance of malarial hemoglobinuria, and believe that 
in our more temperate zones it scarcely ever occurs. Bastianello 
asserts that it is likewise rare in Italy, but more common in Sicily 
and Greece, and very common in the tropics. According to the 
same observer, hemoglobinuria occurs only in infections with the 
estavo-autumnal parasite. A hemoglobinuria due to quinin is like- 
wise said to exist, but is certainly rare, excepting in patients who 
are suffering or have recently suffered from malarial fever. I have 
seen but one instance of hemoglobinuria following the ingestion of 
quinin. To judge from the literature upon the subject, there can be 
no doubt that syphilis may under certain conditions be a potent fac- 
tor in the production of hemoglobinuria. This appears to be par- 
ticularly true of those cases of so-called paroxysmal hemoglobinuria 
in which bloody urine is voided from time to time, the attacks being 
frequently preceded by chills and fever, so as closely to simulate 
malarial fever. Other factors, also, notably cold, appear to be con- 
cerned in the production of this form. 

The occasional occurrence of hemoglobinuria in cases of Ray- 
naud's disease, coincident with attacks of an epileptiform character, 
has been referred to in the chapter on the Blood (see page 41). 

Hemoglobinuria has been observed in a case of leukemia com- 
plicated by icterus. 

Finally, an epidemic hemoglobinuria has been described as occur- 
ring in the newborn associated with jaundice, cyanosis, and nervous 
symptoms : of its causation we are in ignorance. 

While hemoglobinuria is rather uncommon, hematuria is fre- 
quently observed, and will be considered later on, as its recognition 
i- imt dependent upon the demonstration of the albuminous body, 
"hemoglobin," alone in the urine, but upon the presence of red 
corpu-ele-. which in hemoglobinuria are either absent or present 
in onlv very small numbers. 



Literature. — Haemoglobin una : Rosenbach. Berlin, klin. Woch., 1880, vol. xvii. 
pp. 132 and 151. Ehrlich, Zcit. f. klin. Med.. 18*1. vol. iii. p. :x$. Boas, Arch. f. klin. 
Med.. 1885, vo\. xxxii. p. 355. Kobler u. Obermayer, Zeit. f. klin. Med., 1868, vol. 
xiii. p. It;:!. 



411 THE UBINK 

Fibrin. — The occurrence of librin in the urine presupposes the 
presence of fibrinogen and a nbrinogenie ferment. It is seldom 
seen. According to Neubaner and Vogel, the fibrin may occur 
either as coagulated fibrin or in solution. In the former con- 
dition it is at times observed in the form of blood-coagula. when 
its significance is essentially the same as that of hematuria in 
general, although it must be rernenibered that the usual form of 
hamiaturia is not associated with the presence of coagula. Colorless 
coagula of fibrin are seen only in cases of ehyluria or diphtheritic 
inflammation of the urinary passages. On the other hand, mines 
containing fibrinogenic material in solution are likewise seen but 
rarely, and are characterized by the fact that fibrinous coagula sepa- 
rate out only on standing, when they usually cover the bottom of 
the vessel : but at times they may change the entire bulk of urine 
into a gelatinous mass. So far this condition has been observed 
only in cases oi ehyluria ( which see . 

Nucleo -albumin. — The question whether or not nucleo-albumin 
is a normal constituent of the urine is still under dispute. Per- 
sonal investigations have led me to the conclusion that with com- 
plicated methods and large amounts of urine — from 5 to 25 liter- — 
it is always possible to demonstrate its presence both under physio- 
logical and pathological conditions. TTith the usual tests and 
smaller amounts of urine, however, negative results only are obtained 
in strictly normal individuals. According to my experience, tri- 
chloracetic acid, with which Stewart L claims to have obtained posi- 
tive results in every one of the one hundred and fifty normal urines 
which he examine loes not precipitate nucleo-alburnin when this 
is resent in normal amounts. A nucleo-albuminari" recogmzabl 
the available tests foes not exist under -normal conditions. Even under 
pathological conditions nucleo-albumin is by no means always found. 
Sarzin 2 thus was unable to demonstrate its presence in two hundred 
jases which he examined in Senator's clinic. Citron 3 arrived at 
similar results, and of several thousand urines which I have exam- 
ine I in (his direction positive residts were obtained in only a small 
sntage ::' cases. Its presence always indicates increase:! epi- 
thelial desquamation in some portion of the urinary tract. It is 
essentially met with in diseases which directly or indirectly involve 
the integrity of the epithelial lining of the uriniferous tubule-, or of 
the bladder. It has thus been frequently found in cases of acute 
nephritis and associated with febrile albuminuria, although its pres- 
ence even then is not constant. In chronic nephritis it is more fre- 
quently absent than present. In cases of renal hvpenemia and cystitis 
the results are variable. In thirty-two icteric urines Obermayer 4 

1 D. D. Stewart Med News, 1894 

2 D. Sarzin. Ueber Xueleo-albuminansscbeidung. Diss.. Berlin. 1594. 

3 Ueber Mucin im Harn. Diss.. Ber" 1881 

* Obermayer. Cenrralbl. f. klin. Med.. 1S9~2. vol. xiii. p. 1. 



ALBUMINS. U5 

obtained positive results without exception, and it appears thai in 
leukaemia nucleo-albumin is also quite constantly present. During 
the administration of pyrogallol, naphtol, corrosive sublimate, tar 
preparations, arsenic, etc.. as well as in eases of poisoning with anilin 
and illuminating-gas, Large amounts of the substance may be found. 

A.ccording to my experience, nucleo-albumin is frequently ob- 
tained in cases of so-called functional albuminuria, and it is not 
uncommon to find that this is still present when serum-albumin 
and serum-globulin can no longer be demonstrated, even with the 
trichloracetic acid test. Nucleo-albuminuria may thus exist inde- 
pendently of the presence of the more common forms of albumin. 
This observation has also been made by Strauss, who found nucleo- 
albumin only in several cases of cystitis, in one case of chronic in- 
terstitial nephritis, and in one case of emphysema pulmonum with 
renal hyperemia. 

The existence of a hematogenic form of nucleo-albuminuria has 
thus far not been satisfactorily demonstrated. 

Histon and Nucleohiston. — Kolisch and Burian x were able to 
demonstrate the presence of histon in a case of leukaemia in which 
it was constantly present. More recently Krehl and Matthes 2 claim 
to have isolated the same substance in various febrile diseases, such 
as acute peritonitis, following appendicitis, in croupous pneumonia, 
erysipelas, and scarlatina. It is an albuminous body, and was first 
discovered by Ivossel in the red blood-corpuscles of the goose. It 
exists in the leucocytes of human blood in combination w r ith the acid 
leukonuclein, constituting the so-called nucleohiston of Lilienfeld. 

It is not clear in what manner the histonuria is produced ; so 
much, however, seems certain, that it is not solely dependent upon 
increased destruction of leucocytes. 

Nucleohiston itself has been found in the urine in a case of 
pseudoleukemia, by Jolles. 3 

Tests for Albumin. — The recognition of the various albuminous 
bodies which may occur in the urine is based partly upon their 
direct precipitation and partly upon color-reactions when treated 
with certain reagents. 

The number of tests which have from time to time been sug- 
gested is large; many of them after a brief period of use have been 
discarded as useless or uncertain, while others have been employed 
only occasionally, and have not received the recognition which they 
deserve 1 , from the fact that simpler tests exist, that they do not 
possess sufficient delicacy, or that in some instances it is too great. 

1 R. Kolisch u. R. Burian. " Fcber d. Eiweisskorper d. leuk'imischen Harris,'* etc . 
Zeit. f.klin. Med., vol. xxix. p. 371. 

2 L. Krehl u. M. Matthes, 'Ueber febrile Albumosurie," Doutsch. Arch. f. klin. 
Med., vol. liv. p. 508. 

3 A. Jolles, Ber. d. deutsch. chem. Gesellsch., vol. xxx. p. 172; Zeit. f. klin. Med., 
vol. xxxiv. p. 53. 



416 



ihz vs.iyi. 



In the following pages nc attempt is made to describe all of 
these tests, 2nd attention will be directed only to those which are 
generally nsed. and which clinical experience has proved to be of 
valne, precedence being given to those which have been longest in 
use. While some of these are applicable lor demonstrating the 
presence of more than one form of albumin, special tests will also 
be described whereby the various albumins may be individually 
recognized. 

In every sase the urine should be carefully filtered, so as to free 
it from any morphological elemen:-. et ;. . present. To this end. it 
is generally sufficient :: :■- ::r urine through one or two layers 
of Swedish filter-paper. Frequently, however, a clear specimen 
cannot be obtained in this manner : it is then advisable to shake the 
urine with burnt magnesia or talcum, or to mix it with scraps of 
il:er-paper, when it is filtered as usual. 

Tes:5 for Senim-albnmin. — The ^itp.I': Aero Tesi l Fig. .. : ' v . — 

The value of this test, properly . - 
: - 98- plied, cannot be overestimate!, as 

it is not nly simple, but yields an 
amount of information that can 
otherwise be gained only with dif- 
ficulty. Usually the student is ad- 
vised to make use of a test-tube par- 
tially filled with urine, along the 
sides : which concentrated, chemi- 
cally pure nitric acid is allowed to 
flow, so as :: form a layer at the 
TTom of the tube, when in the 
presence of seram-albumin a distinct 
white ring appears at the zone of con- 
tact between the two liquids (Heller's 
test . The pictures thus obtained can- 
not be compared, however, with those 
b e En when the apparently trivial change 
is made of using a conical glass of 
about 2 ounces capacity instead of the 
test-tube. About 20 c.c. of urine are 
placed in the glass, when 6 to 10 
of nitric acid are added by means of a 
pipette, which is carried to the bottom of the vessel ; the acid is slowly 
allowed to escape by diminishing the pressure of the finger up< :»n the 
tube. When this is carefully done the nitric acid forms a distinct 
zone beneath the urine. In the presence of albumin the white 
ring then appears, and varies in extent and intensity with the 

1 J. F. Heller. Arch. f. physiol. xx. path. Chem. u. Micros., 1852, toL v. p. 169. A. 
Robin, TTrologie elinique de la fierce typhoide. Paris, 1877 




Virri; i::i :rs: 



ALBUMINS. 417 

amount of albumin present (Plato XV., Fig. 1). If now the con- 
tout- of the glass are allowed to stand undisturbed — and if small 
amounts arc present, these appear only on standing for several 

minutes — it will be observed that the cloudiness gradually extends 
upward ; and it' much albumin is present, it may be seen to rise 
into the supernatant liquid in the form of small, irregular col- 
umns. This appearance is possibly referable to the partial decom- 
position of uric acid by means of nitric acid, nitrogen and carbon 
dioxide being set free, which, rising to the surface in the form of 
small bubbles, carry the nitric acid upward; coming into contact 
with albumin in solution, this is then precipitated. 

An excess of uric acid is indicated by the appearance, within five 
to ten minutes after addition of the nitric acid, of a distinct ring in 
the clear urine, about 1 to 2 cm. above the zone of contact, which is 
similar in appearance to that due to albumin. If this ring (Plate 
XV., Figs. 1, 2, and 3), which has been appropriately compared to 
a communion wafer, does not appear within five to ten minutes, it 
may be assumed that uric acid is present in diminished amount. 
The degree of increase, on the other hand, may be determined by 
the size of the ring, it being presupposed that the same quantities 
of urine and of the reagent are employed in every case. 

Should more than 25 grammes of urea be contained in a liter of 
the urine examined, an appearance like hoarfrost will be noted on 
the sides of the vessel, which is due to the formation of urea nitrate. 
Spangles of the same substance appear only in the presence of at 
least 45 grammes ; and if 50 grammes or more of urea are contained 
in the liter, a dense mass of urea nitrate may be seen to separate out. 

Biliary urine, when treated with nitric acid containing a little 
nitrous acid, shows the color-play referable to the action of nitric 
acid upon bilirubin (Plate XV., Fig. 4). The production of the colors 
(red, yellow, green, blue, and violet) takes place from above down- 
ward, the green color being the most characteristic ; in the absence 
of the latter the presence of biliary pigment may be positively ex- 
cluded. The presence of albumin is not objectionable, as the color- 
play takes place beneath the albuminous disk. 

In normal urine a transparent ring is also obtained, presenting a 
peach-blossom red ; the intensity of this may vary, however, from a 
faint rose to a pronounced brick color, and is referable to normal 
urinary pigment (Plate XV., Fig. 5). In the presence of urobilin, 
on the other hand, this ring presents a distinct mahogany color. 

Indican is indicated by the appearance of a violet ring (Plate XV., 
Fig. 2) situated above that referable to the normal urinary pigment. 
Its intensity varies with the amount present, from a light blue to a 
deep indigo. 

The milky cloud at the zone of contact of the two fluids may be 
referable not only to the presence of serum-albumin, but also of 

27 



418 THE URINE. 

globulin and albumoses (propeptones), while a negative reaction will 
generally indicate the absence of these bodies. That the uric acid 
ring will be mistaken for albumin is hardly likely if it is remem- 
bered that this never first appears at the zone of contact of the two 
fluids, but always in the uppermost portion of the urine. It is true 
that urines are occasionally observed in which the separation of uric 
acid takes place so suddenly that within a minute or two the entire 
urinous portion of the mixture is completely clouded, resembling the 
appearance presented by a highly albuminous urine. Such an exces- 
sive elimination of uric acid is uncommon, however, and it is to be 
remembered that with uric acid the cloudiness extends from above 
downward, and never from below upward, as is the case with albu- 
min. Should any doubt be felt, it is only necessary to remove a 
few cubic centimeters of this cloudy urine by means of a pipette and 
to heat it gently in a test-tube, when the urine will clear up entirely 
if the precipitate is due to uric acid, while if caused by albumin it 
will remain or become more intense. Should the precipitate caused 
by nitric acid consist of albumoses, it will also clear up entirely, 
to reappear on cooling, the fluid at the same time assuming a 
markedly yellow color. The occurrence of a distinctly yellow color 
in the urine, moreover, which is only partially cleared upon the 
application of heat (and be it remembered that a much higher tem- 
perature is necessary for the solution of a precipitate referable to 
albumoses than of one due to urates), will indicate the existence of 
a mixed albuminuria^i. e., the presence of coagulable albumin and 
albumoses. 

Nitric acid may also cause a precipitation of certain resinous bodies, 
such as those contained in turpentine, balsam of copaiba and tolu, etc. 
If any doubt is felt, the mixture should be shaken with alcohol, 
when the precipitate caused by these substances is at once dissolved. 
The mucinous bodv — nucleo-albumin — which is at times found in 



DESCRIPTION OF PLATE XV. 
The Nitric Acid Test as Applied to the Urine. 

Fig. 1. — The light, colorless ring in the clear urine above shows a slight increase 
in the amount of uric acid ; the large white band denotes a large amount of albumin, 
bordering upon a colored ring, referable partly to indican (blue) and partly to uro- 
rosei'n. 

Fig. 2. — The light ring in the clear urine above denotes a slight increase in the 
amount of uric acid. The bluish-black band is referable to an enormous increase 
in the amount of indican. (Ileus.) 

Fig. 3. — The broad, light band in the clear urine above is referable to an enor- 
mous increase in the amount of uric acid. (Laparotomy.) 

Fig. 4 — The color-play referable to the presence of bilirubin is shown in a dia- 
grammatic manner. 

Fig. 5. — The colored ring is referable to the presence of normal urinary coloring- 
matter. 



PLATE XV. 



FIG. 2. 



FIG. 4. 




FIG. 1. 




FIG. 3. 




FIG. 5. 














*m^ mmmmm/ *> 



ALBUMINS. 419 

the urine is also precipitated by nitric acid, but need not occupy our 

attention at this place. From what has been said, it is manifest 
that the employment of the nitric acid test in the 1 manner indicated 
furnishes much valuable information, and the adoption of the method 
as described not only by hospital students, but by general practi- 
tioners as well, cannot be too strongly urged. 

BOILING Test. — .V few cubic centimeters of urine are boiled in a 
test-tube and then treated with a few drops of concentrated nitric acid, 
no matter whether a precipitate has occurred upon boiling or not. 
If albumin is present, this will separate out as a flaky precipitate, 
which consists of serum-albumin frequently mixed with serum- 
globulin. It is true that albuminous urines will generally yield a 
precipitate on boiling alone; but it must be remembered that unless 
the reaction is decidedly acid a precipitation of normal calcium 
phosphate may occur, owing to the fact that the reaction of the urine 
upon boiling becomes less acid from escape of the carbonic acid held 
in solution. In urines presenting an alkaline or amphoteric reac- 
tion this is very frequently noted, and might give rise to confusion, 
as the precipitate due to calcium phosphate closely resembles that 
referable to albumin. Care must hence be taken to insure a dis- 
tinctly acid reaction, which is best accomplished by the addition of 
nitric acid, when a precipitate referable to phosphates is at once dis- 
solved, while one due to albumin remains, and may even become 
more marked. The quantity to be added should usually be equiva- 
lent to about 0.05 to 0.1 of the volume of urine. Under no con- 
dition should the acid be added before boiling, nor should the 
urine be boiled after its addition, as small amounts of albumin will 
otherwise be overlooked, owing to the fact that hot nitric acid dis- 
solves the precipitate to a certain degree. If, after addition of 
the nitric acid the urine turns a distinct yellow, and if then upon 
cooling a white precipitate appears, the presence of albumoses may 
be inferred. Uric acid will probably never cause confusion, as this 
separates out only upon cooling, and then presents a dark-brown 
color. As in the case of the nitric acid test, so also here, a pre- 
cipitation of certain resins is noted at times which may be recognized 
by their solubility in alcohol. Albumoses are also precipitated upon 
the application of heat, but such precipitates again dissolve when 
the temperature approaches the boiling-point (see page 425). 

Should acetic acid be used instead of nitric acid, great care must 
be taken to avoid an excess, as otherwise the albumin will be dis- 
solved. As this danger diminishes the greater the quantity of salts 
contained in the urine, it is advisable to treat the urine first with a 
few drops of acetic acid until a distinctly acid reaction is obtained, 
and then to add one-sixth its volume of a saturated solution of 
sodium chloride, magnesium sulphate, or sodium sulphate, when 
upon boiling a precipitation of the albumin will occur. Carried 



420 THE URINE. 

out in this manner, the test is absolutely certain and will dem- 
onstrate even minimal amoimts of albumin. If an equal volume 
of a saturated solution of common salt is added to the acidified urine, 
albumoses are also precipitated, but the precipitate dissolves on 
boiling. 

The Potassium Ferrocyanide Test. — A few cubic centi- 
meters of urine are strongly acidified with acetic acid (sp. gr. 1.064) 
and treated with a few drops of a 10 per ceut. solution of potassium 
ferrocyanide, when, in the presence of but little albumin, a faint 
turbidity, or, if much albumin is present, a flaky precipitate, is 
noted, which is best recognized by comparison with a tube contain- 
ing some of the pure filtered urine, both tubes being held against 
a black background. Concentrated urines should be previously 
diluted with water, as albumoses, like serum-albumin and serum- 
globulin, which may be precipitated in this manner, otherwise re- 
main in solution. Here, also, as in the tests described, the presence 
of albumoses may be inferred if the precipitate disappears upon 
boiling, while a partial clearing up, on the other hand, indicates the 
presence of albumoses and coagulable albumin. 

At times the addition of acetic acid by itself is followed by the 
appearance of a cloud in the urine, which may be due to urates or 
to urinary mucin (nucleo-albumin), as already mentioned. In such 
cases the urine should be refiltered, diluted with water, and the test 
again applied. 

v. Jaksch advises the careful addition, by means of a pipette, of 
a few cubic centhneters of fairly concentrated acetic acid, to which a 
little potassium ferrocyanide has been added, when the albumin, as in 
Heller's test, is seen to form a ring at the zone of contact between 
the two fluids. Instead of potassium ferrocyanide, potassium plat- 
inocyanide may also be employed, and has the advantage that the 
test-solution is colorless. 

The Trichloracetic Acid Test. 1 — This test is undoubtedly 
the most delicate of those so far described, but not so delicate that 
a trace of albumin or nucleo-albumin can be demonstrated in every 
urine. An experience based upon the examination of several thou- 
sand urines with this reagent warrants my speaking with a certain 
degree of confidence upon the subject. Very frequently it is pos- 
sible with this method to demonstrate albumin in urines in which 
the more common tests yield negative results, but in which tube- 
casts may nevertheless be found upon microscopical examination. 
The test is applied as follows : by means of a pipette 1 or 2 c.c. of 
an aqueous solution of the reagent (sp. gr. 1.147) are carried to the 
bottom of a test-tube containing the carefully filtered urine, so as to 
form a layer beneath the urine. In the presence of albumin a white 

1 P. Obermayer, Wien. med. Jahrbuch, 1888, p. 375. D. M. Reese, Johns Hopkins 
Hosp. Bull., 1890. 



ALBUMINS. T-M 

ring will be seen to form at the zone of contact between the two fluids, 
varying in intensity with the amount of albumin present. So far as 
the test for albumin is concerned, this reagent possesses an advantage 
over nitric acid in that the colored pines, which are so confusing 
to the inexperienced, are commonly not observed. Serum-albumin, 
serum-globulin, and albumoses are precipitated, the presence of the 
latter being recognized, as in the previous tests, by the fact that the 
precipitate disappears upon boiling and reappears on cooling-. A 
cloud, referable to uric acid, also appears if this is present in exces- 
sive amounts, but disappears upon the application of gentle heat. 
A previous dilution of the urine, moreover, guards against its occur- 
rence. 

Other tests have also been suggested for the detection of albumin 
in the urine, such as the metaphosphoric acid test, the phenol, tannic 
acid, and picric acid tests, that with Tanret's reagent, phospho- 
tungstic and phosphomolybdie acids, and quite recently Spiegler's 
reagent. 

Of these, only the picric acid and Spiegler's test will be cou- 
riered. 

Pickic Acid Test. — The picric acid test is not applicable as a 
test for albumin as such, and is mentioned in this connection only 
because the same reagent is employed with Esbach's quantitative 
method. This is composed of 10 grammes of picric acid and 20 
grammes of crystallized citric acid, dissolved in a liter of distilled 
Mater. If to this solution albuminous urine is added, the mixture 
i- rendered turbid, and after some time a sediment which consists 
not only of albumins, but also of uric acid, kreatinin, and other 
extractives, will form at the bottom of the tube (see Quantitative 
intimation of Albumin). 

Spiegler's Test. 1 — Spiegler's reagent consists of 8 parts by 
weight of mercuric chloride, 4 parts of tartaric acid, and 200 parts 
of water, in which 20 parts of cane-sugar are further dissolved, so 
as to increase the specific gravity of the reagent and permit of its 
being employed, like Heller's test, even in concentrated urines. 
One-third of a test-tube i< filled with the reagent, and the urine 
carefully placed above this by allowing it to flow slowly down the 
Bide <>t" the tube; in the presence of albumin a sharply defined white 
ring will be observed where the two liquids are in contact. Peptone 
gives no reaction, while albumoses are precipitated and may be 
recognized as indicated above. 

Special Test fob Serum-aibumin. — should it be desired, far 
any reason, to demonstrate serum-albumin alone, the urine is ren- 
dered amphoteric or faintly alkaline with sodium hydrate, and is then 
saturated with magnesium sulphate in substance, in order t<> remove 
any globulin. The filtrate is strongly acidified with acetic acid, 

l Spiegler, Wien. klin. Woch., L892, vi.l. v. p. 26. 



IHE URINE 

when a flaky precipitate, appearing npon boiling, will indicate the 
presence of serum-albnmin. 

Patein's tdbumia diiiers from the common serom-albmnin in being 
soluble in acetic a 

Very often, as in the examination for sugar, it is necessary to 
remove any coagulable albumin that may be present, to which end 
the urine is rendered distinctly acid with acetic acid and boiled. An 
examination of the filtrate with potassium ferroeyanide, if the 
amount of acetic acid added was just sufficient, will then yield a 
negative result (see pa^ -_ 

Quantitative Estimation of Albumin. — For the quantitative esti- 
mation of albumin a large number of methods have been devi- ... 
which fact in itself is sufficient to indicate that the majority of them, 
at least, are unsatisiae: : 

Old aIethod by BorciNG. — If only comparative results are 
ed, the old method of boiling a definite amount of urine, 
after the addition of acetic acid, and allowing the albumin : settle 
for twenty-tour hours, may be employed. For this purpose Xeu- 
bauer suggests the use of glass tubes measuring one-half to three- 
quarters of an inch in diameter, which are closed at the lower end 
with a cork. Ordinary test-tubes answer perfectly well, but care 
should be taken that the same quantitv of urine is used in e _ 
case. The tubes are corked and kept for several days for com- 
parison. The results, of course, express only the relative amount 
of albumin present, and it should be remembered that the error 
incurred may amount to as much as 30 or even 50 per cent, of 
the quantity that is found by gravimetric analysis. This is owing 
: the fact that sometimes the albumin separates out in large flakes, 
and at other times in small flakes, and that the decree of preerr i: - 
tion is also influenced by the specific gravitv of the supernatant 
urine. 

V luaeftric Meth:: r Wa mkilikw - 2 — This method can be 
recommended for the quantitative estimation of albumin, as it is 
both simple and accurate. 

Ten : _ :.c. of urine, which are best dilut- : 50 c.c. with 
distilled water, are treated with 2 drops of a 1 per cent, aqueous 
solution of true yellow, and then titrated with a 25 per cent, s lo- 
tion of salicvl-sulphonic acid until a distinct brick-red col : is 
obtained. The number of cubic centimeters of the reagent em- 
ployed, multiplied by 0.01006, will indicate the amount of albumin 
in the 10 or 20 c.c. of urine examined. If the urine is alkali: 
should first be slightly acidified with acetic acid. 

1 Patein. "Aeeto-solnble Albumin in the Triine. ,r Compt. rend, de l'Aead. desS 
1389. Coplin. Phila. Med. Jour., 1S99. p. 933 

a Wassiliew. Eshenedelnik, 189e N St Petersburg, med. Woch.. 1597, Beilage, 

p. 4. 



ALBUMINS. 



423 



~u 



Esbach's Mitiiod. 1 — For clinical purposes, Esbach's method is 
the most convenient. As stated above, his reagent is composed of 
10 grammes of picric acid and 20 grammes of citric acid, 
dissolved in L 000 c.c. of distilled water. Special tubes, Fig. ii ( .». 
termed albuminimeters (Fig. 99), are employed, which 
bear two marks, one, U, indicating the point to which 
urine must be added, and one, /., the point to which the 
reagent is added. The lower portion of the tube up to U 
bears a scale reading from 1 to 7. The tube is filled to 
U with the filtered albuminous urine, and the reagent added 
until the point R is reached. The tube is then closed with 
a -topper, inverted twelve times, and set aside for twenty- 
four hours. At the expiration of this time serum-albu- 
min, serum-globulin, and albumoscs, as well as uric acid 
and kreatinin, will have settled, when the amount pro 
mille in grammes may be directly read off from the scale. 
.V few precautions must, however, be observed in order 
to obtain as accurate results as possible. The reaction of 
the urine should be acid, and if this is not the case acetic 
acid is added. Its specific gravity should, furthermore, 
not exceed 1.00G or 1.008, the proper density being ob- 
tained by diluting with water. The temperature also 
appears to play an important role, the reading generally 
being higher with a low than with a more elevated tern- a J2Ser?" 
perature; 15° C. is best adapted to the purpose. 

The Differential Density Method. 2 — More accurate results 
may be obtained with the following method, which is based upon the 
diminution in the specific gravity of the urine after the removal of 
all albumin, and its comparison with the specific gravity observed 
before. To this end, the urine is treated with a sufficient amount of 
acetic acid to insure complete precipitation of the albumin (see 
below), when its specific gravity is noted. It is then brought to 
the boiling-point, care being taken to guard against evaporation by 
placing the urine in an ordinary medicine-bottle; this is closed with 
a rubber stopper that has been previously boiled in a solution of 
sodium hydrate and washed free from alkali, the stopper being tightly 
fastened with a cord or wire. Thus prepared, the bottle is kept in 
boiling water for ten to fifteen minutes. The urine is filtered on 
cooling, evaporation being again carefully guarded against by filter- 
ing into a bottle through a funnel which has been passed through a 
closely fitting -topper; the funnel is kept covered with a plate of 
glass. The specific gravity is then again determined, and it is best 
in both cases to use a pyknometer. (An accurate hydrometer, grad- 
uated to the fourth decimal, may, however, also be used.) The 

1 Gnttmann, Berlin, klin. Woch., 1886. vol. xxiii. p. 117. 

2 Huppert u. Zah&r, Zeit. f. physiol. Chem., 1886, vol. xii. pp. 107 and 484. 



424 THE URINE. 

decrease in the specific gravity, multiplied by 400, will indicate the 
number of grammes of albumin in 100 c.c. of urine. 

Gravimetric Method. — If special accuracy is required, the 
amount of albumin must be determined gravimetrically as follows : 
a certain amount of urine, after having been acidified with acetic 
acid, so as to insure complete precipitation of all albumin, is boiled ; 
the albumin is then filtered off, dried, and weighed. For this pur- 
pose, 500 to 1000 c.c. of carefully filtered urine should be available. 
A specimen of this, if already acid, is placed in a test-tube, in boil- 
ing water, until coagulation takes place, when it is further heated 
over the free flame and filtered. The filtrate is then tested with 
acetic acid and potassium ferrocyanide. Should no albumin be 
thus demonstrable, the entire amount of urine is treated in the same 
manner, and requires no further addition of acetic acid. If, how- 
ever, the test yields a positive result, it is apparent that the urine 
was not sufficiently acid. The entire volume is then treated with a 
30 to 50 per cent, solution of acetic acid, drop by drop, the mixture 
being thoroughly stirred and specimens tested from time to time, as 
described. When, finally, the urine remains clear or shows only a 
faint turbidity, 100 c.c. or less, according to the amount of albumin 
present, are first heated in boiling water until the albumin begins to 
separate out in flakes, and then carefully brought to the boiling-point 
over the free flame. The supernatant urine is decanted through a 
filter, which has been previously dried at 120° to 130° C. and 
accurately weighed, when the whole amount of the precipitate is 
brought upon the filter. Any albumin remaining in the beaker is 
detached from its sides by means of a glass rod tipped with a piece 
of rubber tubing, and collected by the aid of hot water. The entire 
precipitate is now thoroughly washed with hot water until the wash- 
ings no longer become turbid when treated with a drop of nitric acid 
and silver nitrate ; in other words, until the chlorides have been 
completely removed. The precipitate is further washed with alco- 
hol and finally with ether to remove any fats that may be present, 
when it is dried at 120° to 130° C. until a constant weight is 
reached. If still greater accuracy is required, the dried and weighed 
precipitate is incinerated to determine the amount of mineral ash in 
combination with the albumin, which is then deducted from the total 
weight. The most accurate results are obtained if not more than 0.2 to 
0.3 gramme of albumin is contained in the amount of urine employed. 
A smaller quantity than 100 c.c. should hence be used if a previous 
test with Esbach's albuminimeter shows a higher percentage. 

A glass-wool filter insures a more rapid process of drying — twenty- 
four to thirty hours ; but care must then be had that this is properly 
prepared, so as to guard against a loss of the wool while washing. 

Test for Serum-globulin and its Quantitative Estimation. — To test 
for serum-globulin the urine is rendered alkaline by the addition of 



ALBUMINS. 425 

ammonium hydrate, any phosphates that may thus be thrown down 
being filtered off on standing-. The urine is then treated with an 
equal volume of a saturated solution of ammonium sulphate, when 
the occurrence of a precipitate will indicate the presence of the 
globulin. Ammonium urate may likewise separate out, but this 
oeeurs later. 

According to Paton, the following test may also be employed : the 
urine after having been rendered alkaline with sodium hydrate, — 
any phosphates which may separate out are filtered off, — is carefully 
poured down the side of a test-tube containing a saturated solu- 
tion of sodium sulphate, so as to form a layer above this, when in 
the presence of serum-globulin a white ring will appear at the zone 
of contact. 

If a quantitative estimation of the globulin is to be made, the pre- 
cipitate thus obtained, after about one hour's standing, is collected 
on a dried and weighed filter, and washed thoroughly with a one- 
half saturated solution of ammonium sulphate until a specimen 
of the washings treated with acetic acid and potassium ferrocy- 
anide no longer gives a precipitate. It is then treated as directed 
in the method employed for the quantitative estimation of serum- 
albumin. 

Tests for Albumoses. — A small amount of urine is strongly acidi- 
fied with acetic acid and treated with an equal volume of a saturated 
solution of common salt. In the presence of albumoses a precipitate 
occurs, which dissolves on boiling and reappears on cooling. If 
serum-albumin also be present, which is usually the case, the hot 
liquid must be filtered. The albumoses are found in the filtrate and 
appear on cooling. If the hot filtrate, moreover, is rendered alkaline 
with a solution of sodium hydrate, a red color develops upon the 
addition of a very dilute solution of cupric sulphate, added drop by 
drop (biuret reaction). On boiling with MiUon's reagent a red color 
is also obtained. This reagent is prepared by dissolving 1 part of 
mercury in 2 parts of nitric acid of a specific gravity of 1.42, and 
diluting with 2 volumes of distilled water. 

Sat.kowski's Method. 1 — Fifty c.c. of urine are acidified in a 
beaker with 5 c.c. of hydrochloric acid, and precipitated with phos- 
photungstic acid, the mixture being heated over the free flame, when 
in a few minutes the precipitate will form a resinous mass which 
closely adheres to the bottom of the vessel. The supernatant fluid 
is decanted, and the mass at the bottom, which now becomes granular, 
washed twice- with distilled water, which is likewise removed by 
decantation. The precipitate is then covered with about 8 c.c. of 
distilled water, and treated with 0.5 c.c. of a sodium hydrate solu- 
tion (sp.gr. 1.16). Upon shaking the beaker the mass will dissolve, 

1 E. salkmvski. " UebeT d. Nachweis d. Peptons (Albumosen) im Ham u. d. Daistei- 
lung d. Urobilins," Berlin, klin. Woch., 1887, p. 353. 



426 THE URINE. 

the solution assuming a dark-blue color. This is heated on the free 
flame until the blue color turns to a dirty, grayish-yellow ; the solu- 
tion at the same time becomes turbid, but at times may turn yellow 
and remain clear. This discoloration may be hastened by the further 
addition of a few drops of sodium hydrate solution. As soon as 
this point has been reached, some of the liquid is placed in a test- 
tube, allowed to cool, and then treated with a very dilute solution 
of cupric sulphate (1 to 2 per cent. ) drop by drop ; in the presence 
of peptones the solution assumes a bright-red color, which may be 
brought out still more strongly if the specimen is now filtered. If 
albumin or much mucin is present, these bodies must first be re- 
moved (see pages 422 and 428); but the quantity of urine employed 
is so small that the mucin can usually be disregarded. TTith this 
method, which occupies only about five minutes, 0.015 gramme of 
peptones pro 100 c.c. may be demonstrated without difficulty. 

Salkowski has recently pointed out that urines which are very 
rich in urobilin, as in pneumonia, may give rise to the biuret reac- 
tion even when albumoses are absent. The coloring-matter, it is 
true, may be removed entirely by precipitation with lead acetate or 
subaeetate, but unfortunately a portion of the albumoses is also 
carried down, and the substance may thus escape detection when 
present only in small amounts. He hence suggests that smaller 
quantities of urine, such as 10 c.c, be employed in the test. The 
reaction is then not so well marked, but the results are more re- 
liable. 

Bang's Method. — This method has recently been introduced, 
and is said to be free from the objections attaching to the one pro- 
posed by Salkowski. Ten c.c. of urine are heated in a test-tube 
with 8 grammes of finely powdered ammonium sulphate until the 
salt has been dissolved ; the fluid is then boiled for a moment. The 
hot fluid is centrifugated for one-half to one minute, the supernatant 
fluid poured off, and the sediment stirred with alcohol in an agate 
mortar. The alcohol is poured off, and the residue dissolved in a 
little water : the solution is boiled and filtered, and the filtrate tested 
with sodium hydrate solution and cupric sulphate as described. 
Should the urine be especially rich in urobilin — i. e., manifesting 
a well-marked fluorescence with zinc chloride and ammonia — it is 
best to extract the final aqueous solution with chloroform by shak- 
ing, and to pour off the supernatant fluid, when this is tested with 
cupric sidphate. In this manner it is possible to demonstrate the 
pre-ence of albumoses in a dilution of 1 : 4000—5000. Other con- 
stituents of the urine, with the exception of hamiatoporphyrin, do 
not interfere with the test. Should hsematoporphyrin be present, 
however, which may be suspected if a red alcoholic extract is obtained, 
the urine must first be precipitated with barium chloride. The fil- 
trate, which contains the albumoses, is then examined as described. 



ALBUMINS. 421 



iiinmo- 



[fa centrLfiige is not available, the urine ia boiled with the 
niuni sulphate, when a portion of the album OSes will remain on the 
sides of the tube as a sticky mass. This is washed with alcohol, 
and if necessary with chloroform, dissolved in water, and tested for 

biuret. 

The alcoholic extract may also be used for testing for urobilin. 
To this end, it is only necessary to add a lew drops of a solution 
of zinc chloride, when in the presence of urobilin a beautiful fluores- 
cence will be observed. The test is extremely delicate. 1 

Tests for Bence Jones' Albumin. — The presence of Bence Jones' 
albumin is usually discovered on slowly heating the urine to the 
boiling-point. It will then be noted that at a temperature of from 
50° to 60° C. a more or less intense, milky turbidity develops, which 
on subsequent boiling either disappears entirely or partially, and 
reappears on cooling. The degree to which the urine clears on 
boiling differs in different eases. As I have just stated, the turbid- 
ity may disappear entirely ; but, on the other hand, urines are met 
with in which even a partial clearing can scarcely be made out. 
This is apparently dependent upon the degree of acidity of the urine, 
the amount of mineral salts and of urea present, and probably also 
upon other and still unknown factors. 

Upon the addition of a drop of nitric acid to a few cubic centi- 
meters of such urine a temporary turbidity develops, which disap- 
pears on shaking, but persists if a little more of the acid is added. 
If now the mixture is heated, the albumin first coagulates to a dense 
mass; on boiling, this dissolves, and after a while the liquid becomes 
almost entirely clear, while the turbidity returns, as before, on sub- 
sequent cooling. Similar reactions are obtained with all the common 
reagents for albumin. 

For its complete identification, the albumin should be isolated 
and further examined as follows : larger amounts of urine are pre- 
cipitated by the addition of one and one-half to two volumes of 
96 per cent, alcohol, or by treating with two volumes of a saturated 
solution of ammonium sulphate. In either event the total amount 
of albumin is thrown down. This is then washed with alcohol and 
ether, and dried over sulphuric acid. To purify the substance, it is 
dissolved in boiling water, by the aid of a few drops of a dilute 
solution of sodium carbonate, and dialyzed to running and then to 
distilled water until free from mineral salts. It is then r< precipi- 
tated with alcohol (if necessary, after the addition of a drop or two 
of a dilute solution of hydrochloric acid), washed with absolute 
alcohol and ether, and dried. Thus purified, the albumin is prac- 
tically insoluble in distilled water or saline solution at ordinary tem- 
perature, and only sparingly so at the boiling-point. In boiling 

X E. Rang. "Eineneue Methode ziira Nachweisd. Albumosen im Ham," Deutech, 

med. Woch., 1898, p. 17. 



428 THE URINE. 

water, however, it dissolves with comparative ease after the addi- 
tion of a few drops of sodium carbonate solution. On neutraliza- 
tion no precipitate occurs if a sufficient amount of water is present. 
If such a neutral solution is heated, no change occurs ; but if it is 
now acidified and a certain amount of salt added, the typical reaction 
appears on heating, viz., precipitation between 50° and 60° C. (even 
between 40° and 50° C. if a sufficient amount of salt is present), 
clearing on boiling, and reprecipitation on cooling. 

On digestion with pepsin-hydrochloric acid, as I have said, a 
proto-albumose is obtained among the early products of digestion, 
while a hetero-albumose is not formed. 

Test for (Mucin) Nucleo-albuniin. — The carefully filtered urine is 
treated in a test-tube, drop by drop, with an excess of concentrated 
acetic acid, when the occurrence of a turbidity will indicate the 
presence of nucleo-albumin. 

If the urine contains albumin, this must first be removed by salt- 
ing with ammonium sulphate in substance. The precipitate is then 
dissolved and tested in the usual manner, after dialyzing out the 
salts. Dilution of the urine (1 part to 3 of water) should also be 
practised when doubt is felt, as urates will then not interfere with 
the reaction, nor will the urinary salts be so apt to exert a solvent 
action upon the mucin if they are present in large amounts. 

Ott's test may also be advantageously employed. 1 To this end, 
a few cubic centimeters of urine are treated with an equal volume 
of a saturated solution of common salt, when AlmeVs solution, 
which consists of 5 grammes of tannic acid, 10 c.c. of a 25 per 
cent, solution of acetic acid, and 240 c.c. of 40 to 50 per cent, 
alcohol, is slowly added. In the presence of nucleo-albumin a 
precipitate develops at once. 

Nucleo-albumin is characterized by its insolubility in acetic acid, 
by the fact that it is precipitated by magnesium sulphate, and that 
it does not give rise to the formation of a reducing substance when 
boiled with dilute acids. It is thus readily distinguished from 
globulin and true mucin, with which it has frequently been con- 
founded. Globulin precipitates are easily soluble in acetic acid, and 
mucin when boiled with acid gives rise to the formation of a reduc- 
ing substance. 

In order to remove nucleo-albumin from the urine, this is treated 
with neutral lead acetate, an excess of the reagent being carefully 
avoided. If it is desired to test for peptones, the filtrate is then 
treated with hydrochloric acid and the process continued as described 
above. 

Test for Haemoglobin. — The diagnosis of hemoglobinuria is based 
upon the demonstration of haemoglobin, viz., methsemoglobin, in the 
urine in solution, in the absence of red corpuscles, or at least in the 

1 A. Ott, Centralbl. f. inn. Med., 1895, vol. xvi. p. 38. 



ALBUMINS. 429 

presence of only a very small number, so that an examination in the 

latter direction is also an important factor. 

Bloody urine is generally turbid, and may vary in color from 
bright red to almost black. 

Oxyhemoglobin, as such, can only be recognized by the spectro- 
scope : it gives rise to the appearance of two bands of absorption, 
situated between D and E, as described in the chapter on the Blood. 

The urine to be examined spectroscopically should be rendered 
feebly acid by means of acetic acid, and placed before the open slit 
of the spectroscope in a test-tube, beaker, or similar vessel, when the 
two hands of oxyhemoglobin will be seen, either at once or upon 
carefully diluting with distilled water. If ammonium sulphide is 
now added, the spectrum of reduced haemoglobin will be obtained. 
It must be remembered, however, that more commonly the spectrum 
of metluemoglobin is seen in cases of hemoglobinuria. 

The following tests, which will also indicate the presence of blood 
coloring-matter, cannot be employed to decide the nature of the 
pigment present, as metluemoglobin and oxy haemoglobin will both 
react in the same manner. 

Heller's Test. 1 — A small amount of the urine, or still better a 
portion of the sediment, is made strongly alkaline with sodium hy- 
drate and boiled. On standing, a deposit of basic phosphates forms, 
which in the presence of blood coloring-matter presents a bright-red 
color. This is referable to the formation of haeniochromogen, as may 
be shown by spectroscopic examination. Thus controlled, the test is 
extremely sensitive, and still yields a positive result when the chem- 
ical test alone leaves one in doubt. 2 The deciding band is the first 
between D and E. Care should be had, however, that the solution 
i- cold, as otherwise the hsemochromogen is transformed into luematin 
in alkaline solution. At times, when the urine contains a large 
amount of coloring-matter (bile-pigment, etc.), it may be difficult to 
determine the exact color of the sediment. In such cases the sub- 
sequent examination with the spectroscope, — the lensless instrument 
of Hering or that of Browning suffices, — is invaluable. In the 
absence of such apparatus the procedure of v. Jaksch may be em- 
ployed. To this end, the phosphatic deposit is filtered off and dis- 
solved in acetic acid, when if blood-pigment is present the solution 
becomes red, the color gradually vanishing upon exposure to the air. 
The delicacy of the test is such that oxyhemoglobin can still be 
demonstrated in a dilution of 1 : 4000. 

The GuAIACUM Test. 8 — A mixture of cental parts of tincture of 
guaiacum and oil of turpentine (which has been ozonized by expos- 
ure to the air) is allowed to flow r slowly along the side of a test- 

1 J. F. Heller. Zeit. d. K. K. Geeellsch. d. Aerate zu Wien, 1858, No. 48. 

2 V. Arnold, Berlin, klin. Woch.. 1898, p. 883. 

3 Almen, see Hammarsten, Lehrbuch der physiol. Chem., 3d ed. p. 488. 



430 THE UBTNR 

tube upoD the urine to be examined, in such a manner as to form a 
distinct layer above the urine. In the presence of blood-pigment a 
white ring, which gradually turns blue, will be seen to form at the 
zone of contact. 

Dostogany's Test. 1 — About 10 c.c. of urine are treated with 1 
c.c. of a solution of ammonium sulphide and the same amount of 
pyridin. when in the presence of blood a more or less intense orange 
color develops, especially if looked at from above, against a white 
background. In doubtful cases the examination is to be controlled 
by a spectroscopic examination of the resulting mixture. If blood- 
pigment is present, the spectrum of ha?mochromogen is obtained. 
Should the ammonium sulphide and pyridin be old, a green or brown 
color is imparted to the uriue. which changes to yellow upon the 
addition of ammonium hydrate. 

Test for Fibrin. — Fibrin usually occurs in the urine in the form 
of distinct clots, the nature of which may be determined by thor- 
oughly washing with water, when they are dissolved by boiling in a 
1 per cent, solution of soda or a 5 per cent, solution of hydrochloric 
acid. On cooling, this solution is tested as for serum-albumin. 

Test for Histon. — The urine of twenty-four hours is first examined 
for albumin, and this removed if present. It is then precipitated 
with 94 per cent, alcohol, the precipitate washed with hot alcohol 
and dissolved in boiling water. Upon cooling, the solution thus 
obtained is acidified with hydrochloric acid and allowed to stand for 
several hours. During this time a cloudiness, referable to a large 
extent to uric acid, develops, which is filtered off, and the filtrate "is 
precipitated with ammonia. The precipitate is collected on a small 
filter and washed with ammoniacal water until the washings no 
longer give the biuret reaction. It is then dissolved in dilute acetic 
acid and the solution tested with the biuret test ; if this yields a 
positive result, and if coagulation occurs upon the application of 
heat, the eoagulum being soluble in mineral acids, the presence of 
histon may be inferred. 

CARBOHYDRATES. 

The carbohydrates which may occur in the urine are glucose, lac- 
tose, maltose, dextrin, levulose. certain pentoses, and animal gum. 

Glucose. — Through the researches of vYedenski, v. Udranszky, 
and others, 2 we know that traces of glucose may be encountered in 
the urine under strictly normal conditions. The amount, however, 
is extremely small, and special methods are necessary in order to 

1 Z. Donogany. " Darstellung d. Ha?rnoehroniogen als Eeaction auf Blut," etc.. Vir- 
chow's Arekiv, vol. cxlviil p. 234. 

- A. Bauraaun. Ber. d. Deutsch. chem. Ges.. 1886, vol. xix. p. 3218. N. Wedenski. 
Zeit. f. physiol. Chem.. ls-9. vol. xiii. p. 1'2'2. K. Baisch, Ibid.. 1S94. vol. xviii. p. 193, 
and 1S95. vol. xix. p. 34-. 



CARBOHYDRATES. 431 

demonstrate its presence. With the usual clinical tests normal urine 
i^ apparently free from sugar unless unduly large amounts have 
recently been ingested. In that event a certain amount of glucose 
is eliminated in the urine, constituting the so-called digestive gluco- 
suria of Claude Bernard. 1 

The normal limit to the assimilation of glucose on the part of the 
body economy is subject to considerable variation. Some observers 
thus report that the ingestion of such large amounts as 200 and 250 
grammes does not lead to glucosuria, while others have found sugar 
iu the urine after the administration of 100 grammes. In view of 
the possible relation existing between diabetes and a lowered limit 
to the assimilation of glucose in apparently normal individuals, or at 
least in persons in whose urine glucose cannot be constantly demon- 
strated, this question has created much interest within the last 
few years and has called forth a large amount of work. The major- 
ity of investigators are now in accord in regarding as abnormal a 
glucosuria that follows the ingestion of 100 grammes of chemically 
pure glucose. 

The method usually employed in order to ascertain the power of 
a>similation for glucose on the part of an individual is the following : 

The patient receives 100 grammes of glucose, in substance, dis- 
solved in 500 c.c. of water, on an empty stomach, and is instructed 
to pass his water hourly during the following four to five hours. 
During this time, moreover, no food is to be taken. The individual 
specimens, as well as the urine which has been passed during the 
night, are then tested with Trommer's and INylander's tests, with the 
fermentation test, and with phenyl-hydrazin. A positive result, how- 
ever, is recorded only when sugar can be demonstrated with the fer- 
mentation test. 

Cane-sugar and larger amounts of glucose have also been used ; 
but it is better, on the whole, as Strauss has pointed out, to give 
glucose, and not to exceed the dose of 100 grammes. 

Especially interesting are the results which have been obtained in 
various diseases of the liver, to which organ the important function 
of preventing an undue accumulation of sugar in the blood has been 
repeatedly ascribed. Bierens cle Haen 2 thus reports that of twenty- 
nine cases of various hepatic diseases he found sugar in eighteen 
after the administration of 150 grammes of cane-sugar ; and v. 
Jaksch 3 claims to have obtained positive results in fifteen cases of 
phosphorus poisoning out of forty-three. Strauss, 4 on the other 
hand, states that he found sugar in only two of his thirty-eight 
cases, and has collected one hundred and seven additional cases from 

1 Claude Bernard, Compt. rend, de l'Acad. des Sci., 1859, vol. xlviii. p. 673. 

2 J. C. Bierens de Haen, " Uebcr alimentare Glycosurie bei Lcberkranken," Arch, 
f. Verdauungskrank., vol. iv. p. 4. 

3 v. Jaksch, " Alimentare Glvcosurie," Prag. mod. Work.. 1895, Nos. 27, 31, and 32. 

4 H.Strauss, "Leber und Glycosurie," Berlin, klin. Woch., 1898, p. 1122. 



THE URIBK 

the literature, in only fourteen of which could sugar be demon- 
strated. If we add these together, we have one hundred and forty- 
five cases of various hepatic diseases, with negative results in 88.9 
per cent. Referring to the contradictory results obtained, Strauss 
points out that these may have been accidental in part, but that 
the interpretation which has been offered by v. Jaksch and de 
Hs hq may not have been correct. It is thus possible that in his 
sases phosphorus poisoning other factors besides the changes in 
the liver, such as the action of the poison upon the nervous system, 
as a digestive glucosuria may also occur in eon- 

ti ;>n with other forms of intoxication, as in levers, following the 
administration of large loses of diuretin, in acute alcoholism, etc., 
in which the liver is not the only organ that is involved. Strauss 
further shows that great care must be exercised in the selection of 
the material for such investigations, and believes that errors referable 
to this source may have been incurred by Bierens de Haen. He thus 
cites two cases of hvpertrophic cirrhosis, associated with delirium 
tremens, in which small amounts of sugar could be demonstrated in 
the urine a few days after recovery from the delirium, while shortly 
after negative results only could be obtained. The lowering effect 
of alcoholism upon the limit to the assimilation of glucose is a well- 
known phenomenon, and it would be erroneous to conclude that 
because alcoholism may call forth organic changes in the liver the 
digestive glucosuria in such sases is referable to such alterations, 
aout entering further into the question at this place, it appears 
that diseases of the liver per *e do not materially lessen the as- 
similation of glucose, and that other forces are at the disposal of 
the body to supply the glycogen-forming or retaining power of the 
liver when this becomes insunicient, and that these also must be at 
fault when a digestive glucosuria is observed in association with 
hepatic disorders. 

The association of digestive glucosuria with various diseases of 
the nervous - -tern has been carefully studied by v. Jaksch, 1 
Strumpell, Strauss, 3 n <3ordt. Geelvink, and Arndt. 3 From the 
work of these investigators, it appears that digestive glucosuria is 
rarely seen in spinal diseases, nd is decidedly more common in 
functional die : the central nervous system than in organic 

affections. Of thirty cases of tabes examined by Strauss, digestive 
glucosuria resulted in only one after the administration of 100 
grammes of glucose, and in that one case a family history of diabetes 
- In the neuroses a positive result was noted in forty-two 

out of two hundred and ten cases which I have been able to collect 

1 v. Jaksch, Joe eft. 

5 H Straus?- " Z<ur Lahore v. <L nearogenen xl. <L thvreogenen Glycosarie.'"' Deatseh. 

* JtL Arndt. " Feber alimentare Glycosniie bei Xearopsychaseii." Beriin. klin. 



CARBOIIYDRA TES. 433 

from the literature. Most frequently it is met with in the traumatic 
neuroses, in which Strauss observed the phenomenon in 37.5 per 

cent, of his forty eases ; while in the non-traumatic forms only 14.4 
per cent, were insufficient in this respect. Of the organic diseases 
of the central nervous system, it appears that diffuse cerebral lesions 
referable to alcohol and syphilis are more likely to give rise to this 
form of glucosuria than the more localized lesions. 

A digestive glucosuria is further observed in numerous febrile dis- 
eases, such as pneumonia, typhoid fever, acute articular rheumatism, 
scarlatina, tonsillitis, etc. The amount of sugar usually found varies 
from 0.5 to 3 per cent. ; larger amounts may, however, also be 
encountered, and one case is on record in which 8 per cent, was 
present. 1 

Very common also, as I have indicated, is the digestive glucosuria 
of drinkers, and there can be little doubt that the habitual ingestion 
of large quantities of beer and spirits will in the course of time 
lead to a more than temporary enfeeblement of the carbohydrate 
metabolism. In the course of his investigations in this direction, 
Krehl 2 found that among the Jena students the proportion of those 
in whose urine sugar appeared apparently varied with different kinds 
of beer, but was much greater after morning drinking. Of fourteen 
who drank bock or export beer in the morning, five had glucosuria. 
After the evening drinking, amounting in one case to 7 liters, of 
nineteen only one had sugar in the urine, and with Bavarian beer 
one of eleven. 

Of diseases of the skin, digestive glucosuria is notably associated 
with psoriasis ; and it is interesting to note that the same disease is 
not infrequently seen in diabetic patients. Gross thus records five 
cases, in four of which the psoriasis had existed for many years 
before the appearance of diabetic symptoms. Similar instances are 
recorded by Strauss, Grube, Polotebuoff, Nielssen, Schutz, and others. 
Nagelschmidt 3 was able to produce glucosuria by the ingestion of 
100 grammes of glucose in eight cases out of twenty-five. 

During pregnancy digestive glucosuria is also frequently observed, 
and is by some regarded as a fairly constant symptom and of diag- 
nostic importance. The amount is variable, and while Lanz 4 records 
one case in which 29.6 grammes of glucose were found after the 
ingestion of 100 grammes, such figures are certainly uncommon, 
and as a general rule less than 3 grammes are recovered from the 
urine. After delivery the power of assimilation for glucose no 
longer appears to be subnormal. 

1 R. v. Rleiweis. " Ueber alimentare Glycosurie e saccharo bei acuten, fieberhaften 
Infektionskrankheiten," Centralbl. f. inn. Med., 1900, No. 2. 

2 Krehl, "Alimentare Glycosurie nach Biergenuss," Centralbl. f. Inn. Med., 1897., 
No. 40. 

8 Nagelschmidt, "Psoriasis und Glycosurie," Berlin, klin. Woch., 1900, No. 2. 
4 Lanz, Wien. med. Presse, 1895. vol. xxxvi. 

28 



434 THE URINE. 

Of other pathological conditions in which a digestive glucosuria 
has been observed, may be mentioned acute and chronic lead poison- 
ing, poisoning with nitrobenzol, anilin dyes, opium, atropin, and 
carbon monoxide ; further, the febrile form of embarras gastrique, 
etc. In these conditions, however, the phenomenon has received 
little attention. 

Very important is the fact that in diabetes mellitus the sugar may 
at times disappear from the urine, while its elimination is replaced 
by an excessive excretion of uric acid or phosphates. In such cases 
glucosuria may be produced with ease by the ingestion of 100 
grammes of glucose, a point which may be of value in diagnosis. 
The exhibition of such amounts of sugar in true diabetes while 
glucosuria already exists will cause an increased elimination, while 
this apparently does not occur in other forms of glucosuria. Inter- 
esting further is the fact that in diabetic patients an increased elim- 
ination of sugar can be produced by the administration of full doses 
of copaiba. That this drug is in itself capable of lowering the limit 
to the assimilation of glucose has recently been shown by Bettmann. 
A digestive glucosuria was thus produced in four patients out of 
twelve to whom copaiba had been given for one week in amounts 
varying from 1 to 2 grammes. 

The digestive glucosuria to which reference has been made in the 
preceding pages is generally spoken of as the digestive glucosuria e 
saecharo. Similar results have been obtained after the administra- 
tion of starches in excess, viz., 150-200 grammes. But while a 
digestive glucosuria e saecharo is regarded only as a possible indica- 
tion of a pathological alteration of the carbohydrate metabolism, 
it is generally thought that every glucosuria ex amylo 1 is indicative 
of a definite disturbance in the sense of diabetes, unless special 
factors, such as an increase of the surrounding temperature, dimin- 
ished radiation of heat, or complete lack of muscular activity, are 
active. Strauss, however, has shown that in cases in which a some- 
what more than temporary predisposition toward glucosuria e sae- 
charo exists, as in alcoholics, for example, a coincident tendency 
toward glucosuria ex amylo may likewise be demonstrated. As a 
result of his experiments he concludes that the difference between 
the digestive glucosuria e saecharo and glucosuria ex amylo is essen- 
tially a question of degree. Cceteris paribus, it appears that harm- 
ful influences of a slight character lead to glucosuria e saecharo, 
while grave insults call forth glucosuria ex amylo. It results prac- 
tically that the prognosis in those cases in which digestive glucosuria 
follows a temporary insult is far better than when the carbohydrate 
metabolism is permanently damaged, and especially when a gluco- 
suria ex amylo accompanies a glucosuria e saecharo. In the first 

1 E. Kulz, Beitrage zur Pathol, u. Therap. d. Diabetes, Marburg, 1874, vol. i. p. 110. 



CARBOHYDRA TES. 435 

instance it is scarcely likely that true diabetes will develop in the 
course of time, while in the latter this is at least possible. 

Aside from the digestive form of glucosuria which has just been 
considered, and which is produced artificially, an idiopathic transi- 
tory form is also known to occur. A transitory glucosuria, appar- 
ently of central origin, is thus noted in connection with lesions 
affecting the central as well as the peripheral nervous system, such 
as tumors and hemorrhages at the base of the brain, lesions of the 
floor of the fourth ventricle, cerebral and spinal meningitis, concus- 
sion of the brain, fracture of the cervical vertebrae, tetanus, sciatica ; 
following epileptic, hystero-epileptic, and apoplectic seizures, mental 
shock produced by railroad accidents (traumatic neuroses), etc. ; 
mental strain and worry, fatigue, and anxiety. Glucosuria follow- 
ing epileptic and apoplectic attacks, however, does not appear to be 
so common as is generally believed, v. Jaksch was unable to de- 
monstrate the presence of sugar in fifty recent cases of hemiplegia, 
and in a large number of cases of epilepsy, with urines voided 
within the first few hours following the seizure I have reached only 
negative results. 

Siegmund noted a transitory glucosuria in 52.38 per cent, of 
general paretics, in 7.4 per cent, of epileptics, and in 3.77 per cent, 
of dementia cases, while it was not observed in other mental diseases. 

It is a well-known fact that Claude Bernard experimentally pro- 
duced a transitory glucosuria by puncturing a certain spot in the 
floor of the fourth ventricle, the supposed origin of the hepatic 
vasomotor nerves, and it is not improbable that this neurotic form 
of glucosuria is due to some direct or reflex influence affecting that 
portion of the medulla. 

The transitory glucosuria occasionally observed in acute febrile 
diseases, such as typhoid fever, scarlatina, measles, cholera, diph- 
theria, influenza, and especially malaria, particularly during conva- 
lescence, may possibly be referable to the action of ptomai'ns or 
leukomai'ns upon this centre. Seegen reports five cases of malaria 
with "diabetes" in which both conditions disappeared under the 
administration of quinin. In diphtheria glucosuria appears to be 
of common occurrence. Binet thus obtained a positive result in 
twenty-nine cases out of seventy ; twenty-sever times in severe in- 
fections out of thirty-eight, and twice in mild cases out of thirty- 
two. I have personally found a transitory glucosuria in four cases 
out of thirty-two ; the infection in these was of moderate severity. 
Hibbard and Morrissey arrived at similar results. 1 

A glucosuria of toxic origin has been noted in cases of poisoning 
with curare, chloral hydrate, sulphuric acid, arsenic, alcohol, carbon 
monoxide, morphin, etc., and even after simple transfusion of nor- 

1 C. M. Hibbard and M. J. Morrissey, " Glycosuria in Diphtheria," Jour. Exper. 
Med., vol. iv. p. 137. 



436 THE URINE. 

mal salt solution into the blood. Phloridzin, a glucoside obtained 
from the bark of the root of the apple tree, will likewise cause sugar 
to appear in the urine. The glucosuria thus produced is, however, 
only temporary, and ceases upon withdrawal of the drug. 1 

In patients afflicted with disease of the heart, liver, and kidneys 
Gobbi 2 observed a digestive glucosuria, after the ingestion of from 
100 to 200 grammes of glucose, if diuretin was at the same time 
administered. 

The occurrence of a transitory glucosuria under the conditions 
above mentioned, and which may be met with in almost any disease, 
moreover, while interesting from a theoretical standpoint, must in 
the majority of instances be regarded as a medical curiosity only, 
and it is but rarely possible to draw either diagnostic, prognostic, or 
therapeutic conclusions from its existence. 

A persistent form of glucosuria is noted in connection with certain 
lesions of the brain, especially those affecting the floor of the fourth 
ventricle, and is at times of considerable value in diagnosis. This 
is also observed after removal of the thyroid gland, and in cases in 
which thyroid extract has been administered in unduly large amount. 

A continuous elimination of sugar, however, is noted principally 
in the complex of symptoms to which the term diabetes meUitus has 
been applied, and it is this condition to which the greatest practical 
and theoretical interest attaches. 

Diabetes mellitus is essentially a persistent form of glucosuria 
associated with the occurrence of a more or less intense polyuria and 
a greatly increased elimination of all the metabolic products normally 
found in the urine, with the exception of uric acid, which is usually 
present in diminished amount. In the more advanced cases aceto- 
nuria, lipuria, and lipaciduria may also exist. Diabetes, however, is 
not a persistent form of glucosuria in an absolute sense of the word, 
as periods may occur in the course of the disease when glucose is 
temporarily absent. 

The quantity of sugar excreted may be very large, and 180 to 360 
grammes pro die are amounts which may be frequently observed. 
This quantity may diminish to zero under various conditions, such 
as the occurrence of intercurrent diseases, but often also without any 
apparent cause, and not infrequently in the condition which has been 
termed diabetic coma. Cases are also observed in which from begin- 
ning to end mere traces are eliminated, the total amount of sugar 
not exceeding a few grammes, while the course of the disease rapidly 
tends toward a fatal termination, so that the severity of the pathological 
process cannot be measured by the amount of sugar eliminated. A 
few years ago I had occasion to observe a diabetic patient in whom 
for months a daily examination of the urine never revealed the 

1 Zuntz. " Zur Kenntniss d. Phloridziudiabetes," Du Bois' Arcbiv. 1895, p. 570. 

2 G. Gobbi, " La glycosuria da diuretina," II Policlinico, 1900, No. 5. 



CARBOHYDRATES. 437 

presence of more than 5 to LO grammes of sugar, and in whom 
death occurred after eighteen months. 

At the same time it should he remembered that diabetes cannot 
be excluded by one or even more negative urinary examinations, and 
the value of repeating such examinations three or four hours after 
the exhibition of 100 grammes of glucose, as indicated, cannot be 
too strongly urged. 

Clinicians are in the habit of determining the severity of a case, 
to a certain extent at least, from the condition of the urine under a diet 
free from starches and sugars, and generally regard those cases as the 
more serious in which the glucosuria does not disappear under a diet 
of this character, while a more favorable prognosis is given if the 
sugar disappears. It should be remembered, however, that there 
are numerous exceptions to this rule, and that a light case, — i.e., 
one in which the sugar disappears under appropriate dietetic treat- 
ment, — may suddenly exhibit symptoms seen only in the most 
severe forms, or succumb to one of the numerous intercurrent 
maladies, while apparently severe cases may assume the more benign 
type. 

It may not be out of place in this connection to say a few words 
regarding the specific gravity of the urine. AVhile usually very high, 
varying between 1.030 and 1.060, as pointed out in the chapter 
on Specific Gravity, comparatively low figures are noted at times, 
such as 1.012, corresponding to a quantity of urine not exceed- 
ing 1000 c.c, and implying, of course, a diminished elimination 
of solids. This is especially marked in those cases described by 
Hirschfeld, 1 in which, as pointed out in the chapter on Urea, the 
resorption of nitrogenous material from the digestive tract is below 
the normal. Polyuria, a fairly constant symptom of the more com- 
mon types of diabetes mellitus, is much less pronounced in Hirsch- 
fcld's form, and may be altogether absent, although it is true that 
this may occur in ordinary diabetes also. 

The simultaneous occurrence of glucosuria, acetonuria, lipuria, 
and lipaciduria (which see) is probably always indicative of true 
diabetes. 

It is, of course, impossible to enter here into a detailed considera- 
tion of the origin of diabetes. Suffice it to say that a persistent glu- 
cosuria, aside from nervous influences, may be referable, on the one 
hand, to an inability on the part of the liver to transform into gly- 
cogen all of the sugar which is carried to this organ ; or, on the other 
hand, to an inability on the part of the muscular system of the body 
to utilize all the sugar sent to it. Accordingly, we may distinguish 
between a hepatogenic and a myogenic diabetes. As a matter of fact, 
cases are seen, usually belonging to the milder form of the disease. 

1 F. Hirschfeld, "Uebereine neue klinische Form d. Diabetes," Zeit f. klin. Med., 
vol. xix. pp. 294 and 325. 



438 THE URINE. 

in which the sugar may be temporarily caused to disappear from the 
urine by muscular exercise. On the other hand, again, cases are 
seen, and unfortunately only too frequently, in which, notwithstand- 
ing a total abstinence from carbohydrates and a free indulgence in 
muscular exercise, the sugar does not disappear from the urine. In 
such cases it is permissible to speak of a hepatogenic combined with 
a myogenic diabetes. 

Within recent years it has been shown that pancreatic disease is 
frequently associated with diabetes, and while the number of cases 
in which no pancreatic lesions are discovered is still too large to war- 
rant the conclusion that disease of this organ is invariably associated 
with glucosuria, it still must be admitted that lesions of the pancreas 
are the more frequently met with in diabetes the more carefully the 
organ is examined. So much appears to be certain, that diabetes 
may be produced by pancreatic disease. As to the manner, how- 
ever, in which such a result can occur we are in ignorance. In 
this connection it is interesting to note that, according to Opie, dis- 
ease of the areas of Langerhans more especially is associated with 
the clinical picture of diabetes, while lesions affecting the secreting 
portion of the gland only do not influence the carbohydrate metab- 
olism. 1 

Hirschfeld pointed out the fact that while in the majority of 
diabetic patients the proteid food ingested is quite satisfactorily 
utilized, the assimilation of fats and albumins is much below nor- 
mal in others, and particularly so in cases of diabetes associated with 
pancreatic disease (see also Urea). Observations in this direction 
are as yet very scanty, so that a definite opinion cannot be expressed 
regarding the utility in diagnosis of investigations similar to those of 
Hirschfeld. I have had occasion to observe a diabetic patient for 
some time in whom, notwithstanding that conclusions were reached 
similar to those of Hirschfeld, the existence of pancreatic disease 
could not be determined post mortem. 

Whether or not a renal and a thyroigenic diabetes also exists, as 
has recently been suggested, remains an open question. 2 

Tests for Sugar. — The tests for sugar usually employed in the 
clinical laboratory depend upon the following properties of sugar : 

1. In the presence of alkalies it acts as a reducing agent upon 
certaiu metallic oxides, such as those of copper and bismuth (Feh- 
ling's, Trommer's, Bottger's, and Nylander's tests). 

2. In the presence of yeast (Saccharomyces cerevisise) it under- 

1 Opie, Jour. Exper. Med , 1901, vol. v. p. 527. 

2 Diabetes: J. Seegen, Die Zuekerbildung im Thierkorper, Berlin, 1890, p. 260. 
v. Noorden, Pathol, d. Stoffwechsels, Berlin, 1^93. Seegen, "Ueber d. Zuckergehalt d. 
Blutes von Diabetikern," Wien. med. Woch.. 1886, Nos. 47 and 48. F. W. Pavy, " Ueber 
die Behandlung von Diabetes mellitus," Verhandl. d. X. internat. med. Congr. 1891, 
II., Abt. 5, p. 80. P. F. Richter, " Nierendiabetes," Deutsch. med. Woch., 1899, p. 840. 



CARBOHYDRATES. 439 

goes fermentation, with the formation of alcohol, carbonic acid, 
succinic acid, glycerin, and a number of other bodies, such as amyl 
alcohol, etc. (fermentation test). 

3. With phenylhydrazin sugar forms an insoluble crystalline 
compound — phenylglucosazon. 

4. Solutions of glucose turn the plane of polarized light to the 
right, from which property glucose has also received the name 
dextrose. 

In every case the urine should first be tested for the presence of 
albumin, which should be removed by boiling. 

Tbommer's Test. 1 — A few cubic centimeters of urine are strongly 
alkaliuized with sodium hydrate solution, and treated with a 5 per 
cent, solution of cupric sulphate, added drop by drop, until the 
eupric oxide formed is no longer dissolved. The mixture is care- 
fully heated, when in the presence of sugar a yellow precipitate of 
cuprous hydroxide is formed, which gradually settles to the bottom 
as a sediment of red cuprous oxide. 

It is important to note that while sugar, unless present in mere 
traces, can readily be detected in this manner, other substances are 
or may be present in the urine, such as uric acid, kreatin and krea- 
tinin, allantoin, nucleo-albumin, milk-sugar, pyrocatechin, hydro- 
chinon, and bile-pigment, which likewise reduce cupric oxide. 
Following the ingestion of benzoic acid, salicylic acid, glycerin, 
chloral, sulphonal, etc., reducing substances also appear. These may 
generally be disregarded, it is true, if care is taken not to boil the 
urine after the addition of the cupric sulphate, as the precipitation 
of cuprous oxide in the presence of sugar takes place before this point 
is reached. Unfortunately, however, the test when thus applied 
yields negative results, or results which are doubtful, if traces only 
are present, so that it cannot be utilized, as a rule, in the study of 
transitory or digestive glucosuria. 

Feiilix< r's Test. 2 — This is a modification of the test just described, 
and can be recommended only with the same restrictions. 

Two solutions are employed, which must be kept in separate 
bottles, the one containing 34. ()4 grammes of crystallized cupric sul- 
phate, dissolved in 500 c.c. of distilled water, and the other 173 
grammes of potassium and sodium tartrate and 125 grammes of 
potassium hydrate, dissolved in an equal volume of water. Equal 
parts of the two solutions, mixed in a test-tube and diluted with 
four times as much water, are boiled, when a small amount of urine 
is added. In the presence of sugar a precipitate of the yellow 
hydroxide of copper or of red cuprous oxide will be produced : but 
care should he taken only to warm, and not to boil the solution after 
addition of the urine. 

1 0. Trommer, Annal. d. Chem. u. Pharm., 1841, vol. xxxix. p. 361. 

2 H. Fehling, Ibid., 1849, vol. lxxii. p. 106. 



440 THE URINE. 

Not infrequently it will be observed that upon standing, when no 
precipitation has occurred previously , the blue color of the mixture 
changes to an emerald green, while the solution at the same time 
becomes turbid. Such a phenomenon should not be referred to the 
presence of sugar, as it is in all probability due to the action of other 
reducing substances, such as those mentioned above. 

Bottger's Test with Xylaxder's Modification. 1 — A few 
cubic centimeters of urine are treated with Almen's solution in the 
proportion of 11 : 1. This is prepared by dissolving 4 grammes 
of potassium and sodium tartrate, 2 grammes of bismuth subnitrate, 
and 10 grammes of sodium hydrate in 90 c.c. of water, heating the 
solution to the boiling-point and filtering upon cooling, when it 
should be kept in a colored glass bottle. The mixture of urine 
and Almen's fluid is thoroughly boiled, when in the presence of 
sugar a grayish, dark-brown, and finally a black precipitate, con- 
sisting of bismuthous oxide or of metallic bismuth, is obtained. 
Albumin, if presant, must first be removed, as, owing to the sulphur 
contained in the albuminous molecule, alkaline sulphides would be 
formed upon boiling, and, acting upon the bismuth, give rise to the 
formation of black bismuth sulphide, which might be mistaken for 
metallic bismuth. Rhubarb-pigment, as well as melanin and melan- 
ogen (which see), and free hydrogen sulphide must also be absent, 
as misleading results will otherwise be obtained. 

Xylander's test, as well as those of Trommer and Fehling, is, 
however, not without objections, as a partial reduction of the bis- 
muth subnitrate may be produced by other substances, such as 
kairin, tincture of eucalyptus, turpentine, and large doses of quinin. 

Fermentation Test. 2 — A small piece of ordinary compressed 
yeast is shaken with some of the suspected urine and a test-tube filled 
with the mixture, to which some mercury is added. The tube is then 
inverted into a vessel containing mercury, and allowed to stand in 
a warm place (22°— 28° C). If sugar is present, fermentation will 
occur in the course of twelve hours, and the carbon dioxide formed 
rise to the top of the tube, gradually displacing more and more of 
the urine or mercury as the amount of the gas increases. It is easy 
to demonstrate that the gas thus formed is carbon dioxide by 
introducing a small piece of caustic soda into the urine, when, 
owing to absorption of the carbon dioxide, the liquid will again rise 
in the tube. Very convenient for this purpose also are the saccha- 
rimetric tubes of Einhorn (Fig. 100) or Lohnstein 3 (Fig. 102), 
which are employed as just described, a little mercury being poured 
into the bent limb to guard against escape of gas. As the yeast 
itself, however, may give rise to the formation of a little gas in the 

1 E. Nvlander. Zeit. f. physiol. Chem.. 1833. vol. viii. p. 175. 

2 M. Einhorn. VirehoTv's Archiv. 1885, vol. cii. p. 263. 

3 Lohnstein, Berlin, klin. Woch., 1398. p. 866. 



PLATE 




Plienvl-Glueosazoii Crystals obtained, from a Diabe:: : Urine 



CARBOHYDRATES. 



441 



absence of sugar, it will always be well to make a control-test with 
normal urine — t. e., to prepare a similar tube with normal urine 
mixed with yeast, and to allow this to stand at the same temperature. 
It" a positive result is thus obtained, there ean be no doubt as to the pres- 
ence of a fermentable substance in the urine. This, however, is not 
necessarily glucose, as other carbohydrates, such as lactose, maltose, and 
levulose, may likewise undergo fermentation. Still, if large amounts 
of gas are obtained, and if Trommer's test also yields a positive result, 
it will be fairly safe to regard the substance present as glucose. 

Fig. 100. 




' 



T'ri 



Einhorn's saccharimeter. 



Phenylhydrazin Test. 1 — As originally proposed by v. Jaksch, 
the test is conducted as follows : 6 to 8 c.c. of urine are treated 
with 0.4 to 0.5 gramme of phenylhydrazin hydrochlorate and 1 
gramme of sodium acetate, and warmed until the salts have been 
dissolved, a little water being added if necessary. The tube is 
placed in boiling water for twenty to thirty minutes, and then 
transferred to a beaker filled with cold water. If sugar is pres- 
ent in moderate amounts, a bright-yellow crystalline deposit will 
at once be thrown down and partly adhere to the sides of the tube. 
But even in the presence of mere traces a careful microscopical ex- 
amination will reveal the presence of crystals of phenylglucosazou 
(Plate XVI.). These are seen singly or arranged in bundles and 
sheaves composed of very delicate bright-yellow needles which are 
insoluble in water. 



1 v. Jaksch, Zeit. f. klin. Med., 1886, vol. xi. p. 20. 



442 THE UBINE. 

Still more convenient is the following modification of the test, as 
suggested by Kowarsky : 1 5 drops of pure phenylhydrazin are 
mixed in a test-tube with 10 drops of glacial acetic acid and 1 c.c. 
of a saturated solution of common salt. A white caseous mass 
results, which consists of phenylhydrazin hydrochlorate and sodium 
acetate. To this, 3 c.c. of urine are added, when the mixture is 
boiled for two minutes and then set aside to cool. Should more than 
0.5 per cent, of sugar be present, the typical crystals begin to sepa- 
rate out after two minutes, and may be recognized with the naked 
eye. In the presence of smaller amounts the mixture should be 
allowed to stand for from fifteen to twenty minutes, or, if traces 
only are present, for one hour. 

This test, properly applied, is undoubtedly not only the most deli- 
cate, but at the same time the most reliable, as no other substances 
which may be present in the urine, excepting maltose and certain 
pentoses, will give rise to the formation of an osazon. Hence, when- 
ever doubt is felt as to the nature of a substance reacting in a posi- 
tive manner with the reagents described above, recourse should be 
had to this test. It has been stated that maltose forms an exception ; 
this, however, will never become embarrassing, as the microscopical 
appearance of the maltosazon crystals differs from that of the phenyl- 
glucosazon. The melting-point of phenylglucosazon (205° C), 
moreover, is about 15 degrees higher than that of the maltosazon — 
190°-191° C. To determine this point, it is necessary to filter 
off the osazon, and, after washing with water, to dissolve it upon a 
filter by means of a little hot alcohol. From this alcoholic solution 
it is reprecipitated by water, when it may be collected and dried over 
sulphuric acid. The melting-point is then determined according to 
the usual methods. 

The pentosazons also can be readily distinguished from glucosazon 
by their melting-points (which see). 

The amount of lactose which may be found in the urine is far too 
small to give rise to the formation of an osazon when the test is 
directly applied to the urine. 

With the conjugate glucuronates phenylhydrazin also combines to 
form crystalline compounds, but these may likewise be distinguished 
by their melting-points and the form of the crystals. Such com- 
pounds, moreover, are usually not present in amounts sufficient to 
give rise to confusion (see Glucuronic Acid). 

Polarimetric Test. — Glucose turns the plane of polarized light 
to the right, but the same may be said of maltose, the degree of 
polarization of which is even more marked, so that it may be impos- 
sible to state in a given case whether such rotation is referable to a 
large quantity of glucose or to a smaller quantity of maltose. The 

1 A. Kowarsky, " Zur Vereinfachung d. Phenylhydrazinprobe," Berlin, klin. 
Woch., 1899, p. 412. 



CARBOHYDRATES. 



443 



latter substance, however, occurs in the urine but rarely, and may be 
recognized not only l>y the microscopical appearance of its osa/.on, 
but also by the fact that its power of reduction is increased in the 
presence of sulphuric acid and by the application of heat. 

An error which may further arise with the employment of the 
polarimetric method is referable to the fact that if glucose is pres- 
ent in only small amounts, while the urine contains large quantities 
of t i-oxy butyric acid, the latter turning the plane of polarized light 
to the left, it may happen that the rotation in this direction will neu- 
tralize or even counterbalance any rotation to the right which may 
be due to glucose. In such cases, however, the urine will react in a 
positive manner with the other reagents described, and the fermented 
urine will, moreover, turn the plane of polarization still more strongly 
to the left, indicating the presence of a dextrorotatory substance, and 
in all probability of glucose. 

The delicacy of this method varies with the instrument employed ; 
the figures given below were obtained with the apparatus of Lippich, 
which yields the best results. 

(For a description of this method see the Quantitative Estimation 
of Sugar by Means of the Polarimeter.) 

Table showing the Delicacy of the Tests described. 

Trommer's test 0.0025 per cent. 

Fehling'stest 0.0008 

Nylander's test 0.025 

Fermentation test 0.1-0.05 " 

Phenvlhvdrazin test 0.025-0.05 " 

Polarimetric test 0.025-0.05 " 

Table showing the Behavior of the Various Forms of Sugar which 
may occur in the Urine toward the Tests described. 



Trommer's. viz. 
Fehling's test. 



Nylander's Fermenta 



Glucose. Positive reaction. 



test. 



Positive 
reaction. 



tion test. 



Phenyl hydrazin 
test. 



Levulose. Positive reaction. Positive Positive 



Maltose. Positive reaction. 



Lactose. Positive reaction. 



Laiose. 



reaction. 



Positive 
reaction. 



reaction. 



Positive 
reaction. 



Positive 
reaction. 



Positive Positive reaction 
reaction. melting-point 
205° C. 



Same osazon ob- 
tained as with 
glucose, only 
more rapidly. 

A maltosazon is 
formed; melting- 
point 190°-191° C. 

No reaction in the 
concentration in 
which it may oc- 
cur in the urine ; 
melting-point 



Polarimetric 
test. 



No re- 
action or 
only a 
very faint 
one. 



Positive reaction 
on boiling only ; 
1.2-1.8 per cent. 
more is obtain- 
ed than by the 
polarimeter. 



Rotation toward 
the right. 



Rotation toward 
the left. 



Rotation toward 
the right. 



Rotation toward 
the right; in- 
creased by boil- 
ing with a 2.5 per 
cent, solution of 
sulphuric acid. 



Positive No reac- With phenylhy- No reaction, or ro- 

reaction. tion. drazin a yellow- tat ion toward 

ish brown, non- the left. 
crystallizable oil 

is "obtained. 



444 THE URINE. 

Clinically, it is unimportant to search for minute traces of sugar, 
such as may be found in every normal urine, and the reader is 
referred to special works on physiological chemistry for a considera- 
tion of the methods generally employed (see method of Baumann 
and v. Udranszky. 

Quantitative Estimation of Sugar. — The methods used in the 
quantitative estimation of sugar are essentially based upon the quali- 
tative tests described. 

Fehling's Method. 1 — Fehling's solution prepared as described 
above is of such strength that the copper contained in 10 c.c. is 
completely reduced by 0.05 gramme of glucose. If then urine is 
carefully added to this quantity until complete reduction takes place, 
the amount of sugar contained in a given specimen of urine can be 
readily calculated according to the following equation : 

y : 0.05 : : 100 : x ; and x = — , 

y 

in which y indicates the number of cubic centimeters of urine 
required to reduce the 10 c.c. of Fehling's solution, and x the amount 
of sugar contained in 100 c.c. of urine. 

As the best results are obtained only if from 5 to 10 c.c. of urine 
are used in one titration, it is usually necessary to dilute the urine 
to the required degree ; in the determination of this point the specific 
gravity may serve as a guide. As a general rule, urines of a specific 
gravity of 1.030 should be diluted five times, and if the density is 
still higher ten times. To be certain that the proper degree of 
dilution has been reached, 5 c.c. of Fehling's solution are treated 
with 1 c.c. of the diluted urine, a little caustic soda solution and 
distilled water being added to make in all about 25 c.c. This mixt- 
ure is thoroughly boiled ; if the fluid still remains blue, another 
1 c.c. of diluted urine is added, and so on, until the last two tests 
differ by 1 c.c. of urine, the last cubic centimeter added causing a 
separation of cuprous oxide. In this manner the percentage of 
sugar may be approximately determined. Albumin, if present, 
must first be removed by boiling. 

Ten c.c. of Fehling's solution diluted with 40 c.c. of water are 
placed in a porcelain dish and boiled. While boiling, the diluted 
urine is added from a burette, 0.5 c.c. at a time, when, as a rule, the 
precipitated cuprous oxide will rapidly settle, so that gradually a 
white bottom may be seen through the blue field, the color of which 
becomes less and less intense upon the further addition of urine 
until finally the solution is almost colorless. "When this point is 
reached the urine is added drop by drop until the decolorization is 
complete. The degree of dilution multiplied by 5 and the result 
divided by the number of cubic centimeters of diluted urine em- 

1 Loc. cit. 



CARBOHYDRATES. 



445 



ployed will then indicate the percentage-amount of sugar. In the 
following table the percentage results corresponding to the number 

of cubic centimeters of undiluted urine employed will be 1'onnd. 

SUGAR. — Quantity of Glucose pro lifer, corresponding to the number of cubic centimeters 
U>r the complete reduction of 10 cubic centimeters of Fehling's solution. 





1 


A 


ft 

41.68 


_3_ 
10 


_4_ 
10 


A 


ft 


7 
10 


_8_ 
10 


i% 


1 




45.44 




35.70 


33.32 


31.24 


29.40 


27.76 


26.30 


2 






22.72 


21.72 


20.84 


20.00 


19.22 


18.50 


17.84 


17.24 


3 


16.66 


16.00 


15.62 


15.14 


14.15 


14.28 


13.88 


13.50 


13.14 


12.82 


4 


12.50 


12.18 


11.90 


11.62 


11.36 


11.10 


10.86 


10.62 


10.40 


10.20 


5 


10.00 


9.80 


9.60 


9.42 


9.24 


9.08 


8.92 


8.76 


8.62 


8.50 


6 








7.92 


7.80 


7.68 


7.56 


7.44 


7.34 


7.24 


7 


7.14 


7.04 


6.94 


6.86 


6.78 


6.66 


6.56 


6.48 


6.40 


6.32 


8 


6.24 


6.16 


6.08 


6.02 


5.94 


5.88 


5.80 


5.74 


5.68 


5.60 


9 


5.54 


5.48 


5.42 


5.36 


5.30 


5.24 


5.20 


5.16 


5.12 


5.06 


10 


5.00 


4.9 t 


4.'.") 


4.82 


4.78 


4.76 


4.70 


4.66 


4.62 


4.58 


11 


4.54 


4.50 


4.46 


4.42 


4.38 


4.34 


4.30 


4.26 


4.22 


4.20 


12 


4. If. 


4.14 


4.12 


4.08 


4.04 


4.00 


3.98 


3.96 


8.92 


3.86 


13 


3.84 


3.80 


3.78 


3.76 


8.74 


3.70 


3.68 


3.66 


3.62 


3.58 


14 


3.56 


3.54 


3.52 


3.48 


3.46 


3.44 


3.42 


3.40 


3.36 


3.34 


15 


3.32 


3.32 


3.28 


3.26 


3.24 


3.22 


3.20 


3.18 


3.16 


3.14 


In 


3.12 


3.10 


3.08 


3.04 


3.04 


3.02 


3.00 


2.98 


2.96 


2.94 


17 


2.94 


2.92 




2.88 


2.86 


2.84 


2.82 


2.82 


2.80 


2.78 


18 


2.76 


2.76 


2.74 


2.72 


2.70 


2.70 


2.68 


2.64 


2.64 


2.64 


19 


2. '••■_> 


2.62 


2.60 


2.60 


2.58 


2.56 


2.56 


2.54 


2.52 


2.52 


20 


2.50 


2.50 


2.48 


2.48 


2.44 


2.42 


2.42 


2.40 


2.40 


2.38 


21 


! - 


2.36 


2.34 


2.34 


2.32 


2.32 


2.30 


2.30 


2.28 


2.28 


22 




2.26 


2.24 


2.24 


2.22 


2.22 


2.20 


2.20 


2.18 


2.18 


- 


2.16 


2.16 


2.14 


2.14 


2J2 


2.12 


2.12 


2.10 


2.10 


2.10 


24 


2.08 


2.08 


2.06 


2.06 


2.06 


2.04 


2.04 


2.02 


2.02 


2.02 


-■ 


2.00 


1.98 


1.98 


1.96 


1.96 


1.96 


1.94 


1.94 


1.92 


1.92 


26 


1.92 


1.92 


1.90 


1.90 


1.88 


1.88 


1.88 


1.86 


1.86 


1.86 


27 


1.-4 


1.-.' 


1.82 


1.82 


1.82 


1.80 


1.80 


1.80 


1.80 


1.80 


-- 


1.78 


1.76 


1.74 


1.74 


1.74 


1.74 


1.74 


1.74 


1.74 


1.72 


29 


1.72 


1.70 


1.70 


1.70 


1.70 


1.68 


1.6S 


1.68 


1.68 


1.66 


30 


1.66 


1.66 


1.65 


1.63 


1.63 


1.62 


1.62 


1.62 


1.62 


1.62 



Unfortunately, it is difficult, as a general rule, to determine ex- 
actly the point when all the copper has been reduced — i. e., the point 
at which the blue color has entirely disappeared. When it is thought 
that this has been reached, about 1 c.c. should be filtered through 
thick Swedish filter-paper, and the filtrate (which must be absolutely 
clear) acidified with acetic acid and treated with a drop or two of a 
solution of potassium ferrocyanide. If unreduced copper is still 
present in the solution, a brown color will result, indicating that 
sufficient urine has not been added. But if, on the other hand, no 
brown discoloration is noted, it is possible that the desired point lias 
been passed, when the titration should be repeated. At times the 
precipitate will not settle at all, and even pass through the filter, so 
that it is practically impossible to determine the end of the reaction. 
In such cases the following procedure, suggested by Cause, will be 
found of value : 

Ten c.c. of Fehling's solution are diluted with 20 c.c. of distilled 
water and treated with 4 c.c. of a 0.0") per cent, solution of potas- 
sium ferrocyanide. While boiling, the diluted urine is added drop 
by drop until the blue color entirely disappears. A precipitate does 
not form with this method. 



446 THE URTSK 

In order to obtain reliable results, however, the Fehling solution 
must be prepared with great care and its strength determined. This 
may be done in the following manner : 0.2375 gramme of pure 
crystallized cane-sugar, dried at 100° C. is dissolved in 40 c.c. of 
[istQled water, to which 22 drops of a 0.1 per cent, solution of sul- 
phuric acid have been added. This solution is kept on the boiling 
water-bath for an hour, when it is allowed to cool and diluted to 
100 c.c. with distilled water. Twenty c.c. of this solution will then 
contain exactly 0.05 gramme of glucose, corresponding to 10 c.c. of 
Fehling' s solution, if this is of the required strength. If too strong, 
so that 21 c.c. of the sugar solution, for example, are required to 
obtain a complete reduction of the copper, the strength of Tehling's 
solution may be determined according to the equation : 20 : 0.05 : : 
21 : x : and x = 0.0525. If too weak, on the other hand, so that 
19 cCj for example, are required, its strength is similarly deter- 
mine! : 20 : 0.O5 : : 19 : x : and x = 0.0475. 

Kvapp's Method. 1 — This method is said to be more satisfactory 
than that of Fehling. Daylight is not necessary ; the method is 
simpler, and it is applicable even in cases in which the amount of 
sugar is small ; and the solution keeps for a long while. 

The principle of the method depends upon the observation that 
mercuric cyanide in alkaline solution is reduced to metallic mercury 
in the presence of sugar. The solution required should contain 10 
grammes of chemically pure, dry mercuric cyanide and 100 c.c. of 
a solution of sodium hydrate (sp. gr. 1.145) to the liter. Twenty 
c.c. of this solution correspond to 0.05 gramme of glucose. 

Method. — Twenty c.c. of the solution are placed in a small 
ret n and diluted with 80 c.c. of water. If we have reason to 
suppose that the urine contains less than 0.5 per cent, of sugar. 40 
to 60 c.c. are sufficient. The solution is then heated to the boiling- 
point, when the diluted urine (see below) is added, at first 2 c.c. 
at a time, then 1 c.c, 0.5 c.c, 0.2 c.c. and 0.1 c.c, as the final 
p^int is approached. After each addition the solution is boiled for 
one-half minute. As the end-reaction is approached the solution 
clears, and the mercmy. together with the phosphates, settles to the 
bottom. The final point is determined by placing a drop of the 
supernatant fluid upon a piece of clean, white Swedish filter-paper, 
and holdincr this first over a bottle containing concentrated hydro- 
chloric add and then <>ver one containing a saturated solution of 
hydrogen sulphide. If all the mercuric cyanide has not been 
reduced, a yellow spot will result, the color of which becomes the 
inore manifest if it is compared with one which has not been ex- 

«sed to the action <:>£ hydrogen sulphide. As soon as the mercury 
is -'rely reduced the reading is taken. 

Example. — Supposing that 15 c.c. of urine have been required, the 

1 K. Knapp. Annal. d. Chem. u. Pharm.. 1570. vol. cliv. p. 252. 



CARBOHYDRATES. 447 

corresponding amount of sugar is then found according to the fol- 
lowing equation, 20 c.c. of Knapp's solution requiring 0.05 gramme 
of sugar for its reduction : 

15 : 0.05 : : 100 : x ; 15 x = 5 ; and x = 0.333 per cent. 

Precautions : 1. Albumin must first be removed. 

2. The urine should not contain more than 0.5 to 1 per cent, of 
sugar. The urine is hence diluted, if necessary, as with Fchling's 
method. 

Differential Density Method. 1 — This method is very useful 
in clinical work, and should be preferred to the more uncertain titra- 
tion with Fehling's solution, unless considerable experience has been 
acquired with the method. 

The specific gravity of the urine is accurately ascertained by 
means of a pyknometer, or a hydrometer graduated to the fourth 
decimal and provided with a thermometer indicating tenths of a 
degree. The temperature at which the specific gravity is taken 
should be that for which the hydrometer has been constructed, the 
urine being heated or cooled to the desired degree. One hundred 
to 200 c.c. are then set aside in a flask, after the addition of some 
yeast which has been washed free from mineral material, loosely 
stoppered or provided with an arrangement like the one shown in 
the accompanying figure (Fig. 101). After twenty-four hours if 
but little sugar is present, or forty-eight hours if there is much, the 
specific gravity is again determined under the precautions given, 
after having filtered the urine. The difference in the specific gravity 
is multiplied by 230, an empirical factor which has been found by 
dividing the amount of sugar ascertained by titration or polarization 
with the difference in the density of the urine after fermentation. 
The result indicates the percentage of sugar. The process may be 
hastened if to each 100 c.c. of urine 2 grammes of potassium and 
sodium tartrate and 2 grammes of diacid-sodium phosphate are added, 
with 10 grammes of compressed yeast, and the mixture is allowed 
to stand at a temperature of from 30° to 34° C. If but little sugar 
is present, two to three hours will be sufficient. 

That portion of the urine of which the specific gravity is deter- 
mined before fermentation should really be treated in the same man- 
ner. It will suffice, however, to add 0.022 to the specific gravity 
found, to make up for the increase that would otherwise be observed 
in the second specimen owing to addition of the salts. 

In every ease the urine must be perfectly fresh, as fermenta- 
tion generally begins spontaneously, even after standing a short 
time. 

Einhorx's Method. — This will answer very well for ordinary 

1 Eoberts, Lancet, 1862, i. p. 21. Worm-Muller, Pfliiger's Archiv, 1884, vol. xxxiii. 
p. 211, and 1885, vol. xxxvii. p. 479. 



448 



THE URINE. 



Fig. 101. 



purposes. Two especially constructed and graduated saeeharimetric 
tubes (Fig. 100) are used, one of which is tilled with a mixture of 
the suspected urine and yeast, and the other with normal urine and 
yeast, as a control. The tubes are set aside at a temperature of 
from 30° to 34° C. when the percentage-amount of sugar in the 
urine is read off from the column of carbon 
dioxide formed. Should the second tube 
also show a small amount of gas, the figure 
corresponding to this amount is deducted 
from the first. 

Lohxsteix's Method. — A very conve- 
nient modification of Einhorn's instrument, 
and one furnishing more accurate results, 
has been introduced by Lohnstein. 1 As 
will be seen from the accompanying figure 
(Fig. 102), this is essentially a U-tube open 
at both ends. The longer limb is closed 
during the process of fermentation by a 
ground-glass stopper. This stopper is pro- 
vided with an air-hole, to which a similar 
hole corresponds in the drawn-out portion 
of the tube. The apparatus is filled with the 
urine to be examined, through the bulb A, 
while the two air-holes at B are in commu- 
nication. Care should be had that the liquid stands exactly at the 
mark 0. The stopper is then turned so that all communication 
between the air and the urine is cut off. A little mercury is finally 
poured into the saccharimeter. when the instrument is placed in a 
vessel containing water at 35°— 40° C, and maintained at a temper- 
ature of about 30° C. After twelve hours the percentage of sugar 
is read off directly. 
Precautions : 1. 
dioxide, it is well 




Flask for the approximate 
estimation of sugar by fer- 
mentation. (V. JaKSCH." 



As every urine contains traces of free carbon 
to remove this by boiling if we have reason to 
suppose that only a small amount of sugar is present. Before 
adding the yeast the urine is, of course, cooled to the surrounding 
temperature. 

2. As the instrument yields satisfactory results only if the urine 
contains less than 1 per cent, of sugar, it is necessary to dilute it 
with water when more is present. The specific gravity may here 
serve as an index : urines of a specific gravity up to 1.018 are 



when 

an index 
examined directlv 



from 1.018 to 1.022 they are diluted twice. 

from 1.022 to 1.028 five times, and those above 1.028 ten times. 

3. A test-tube, provided with the necessary marks for diluting the 

urine, accompanies the instrument. In every case a globule of yeast, 



1 T. Lohnstein. "Em neues Gahrungssaccharometer. 
p. 866. 



Berlin, klin. Woch., 1595, 



CARBOHYDRATES. 



44 9 



approximately 6—8 mm. in diameter, is added to the urine and shaken 
in the tube until an even suspension has been reached. 1 

POULRIMETRIG METHOD. — Forthis purpose the saeehariiueter of 

Soleil- Ventzke is very convenient (Fig. 103). This consists essen- 
tially of a Nicol prism, A, which may he rotated about the axis of 
the apparatus ;>a second Xicol prism, at P; vertically placed com- 
pensating prisms, consisting of dextrorotatory quartz, at E, which 
may be moved horizontally by means of 
a rack-and-pinion adjustment, turned by 
a milled head at K, so that light can pass 
through a thicker or thinner layer of the 
dextrorotatory quartz. At F is a plate 
of laevorotatory quartz cut perpendicularly 
to the optical axis, and covering the en- 
tire field of vision ; at H biquartz plates 
of Soleil, and at I an Iceland-spar crystal ; 
BC represents a small telescope, by means 
of which the biquartz plates can be accu- 
rately focussed. When the compensation- 
prisms of this apparatus are in a certain 
position the laevorotation of the plate F 
will be exactly compensated, and the two 
halves of the field of vision present the 
same color, while the zero of the scale X 
will coincide with the zero of the vernier 
Y, arranged on the upper surface of the 
compensators. Any change in this posi- 
tion produced by turning the screw K 
will cause the appearance of a different 
color in each half of the field of vision. 
If now, with a zero-position, an optically 
active dextrorotatory or laevorotatory sub- 
stance is interposed, the color of each half of the field of vision will 
become altered, but may be equalized again by changing the position 
of the compensators, the degree of change necessary to produce this 
result constituting an index of the pow r er of rotation of the solution 
interposed in the tube M. 

Soleil- Ventzke's apparatus is constructed in such a manner that 
if a solution of glucose is employed, the length of the tube M being 
10 cm., every entire line of division on the scale will indicate 1 per 
cent, of sugar. 

The tube of the saccharimeter should be carefully w r ashed out with 
distilled water, and at least once or twice with the filtered urine, 
when it is placed on end upon a flat surface and filled with the 

1 Lohnstein's saccharimeter may be procured from R. Kallmeyer & Co., Oanrein- 
burger Str. 45, Berlin. 

29 




Lohnstein's saccharimeter. 



450 



THE URINR 



urine. so that this forms a convex cup at the end. The glass 
plate is now carefully ad/usted. so as to guard against the admission 
of babbles of air. The metallic cap is placed in position, care 
being taken to avoid undue pressure. The examinations are made 
in a dark room : an irdinary lamp is used, and several readings are 
taken, until the differences do not amount to more than 0.1 or 0.2 
cent Tne tabes should be thoroughly cleansed immediately after 
the experiment. 

In every case the filtered urine shoo] I e free from albumin, and. 
if markedly colored, should Y :- ] reviously treated with neutral lead 
acetate in substaa filtered. 

If it is desired to demonstrate only the presence of sugar, the 
compensa: >rs are first brought to the zero-position. If now. upon 



Fig. 103. 



S?«0li 




Soleil-Yentake i 5i.ccharim.eter. 



interposition of the tube filled with urine, a difference in the color 
of the two halves of the field of vision is noted, the presence of an 
[cally active substance in the urine may be assumed : and if the 
ration is at the same time to the right, the presence of glucose is 
rendered highly probable, while a deviation to the left will generally 
be referable to levulose or /^-oxybutyria acid. Indican. peptones 
(albumoses i, cholesteriii. and certain alkaloids, it is true, also turn 
the plane of polarization to the left : but as a rule these substances 
need not be considered, as cholesterin occurs but rarely, and indican 
is usually present in only small amounts in diabetic urines. Albu- 
moses. if present, must first be removed. Lactose and maltose, 
which also turn the plane of polarization to the right, may be dis- 



CARB01IYDRA TES. 45 1 

tinguished from each other and from glucose by the phenylhydrazin 
test. Levulose turns the plane of polarization to the left. ()\v- 
butyric acid is practically always associated with the presence of 
glucose, and may he recognized by allowing the urine to undergo 
fermentation, when the filtered urine will become distinctly lsevo- 
rotatory. 

Bremer's Diabetic Urine Test. 1 — The test is based upon the 
different behavior toward certain anilin dyes of diabetic, as compared 
with non-diabetic, urine. If a trace of a mixture of 2 parts of eosin 
and •*) parts of gentian-violet, for example, is added to non-diabetic 
urine, it will be observed that the urine gradually dissolves the eosin 
and assumes a yellowish or bright-red color, while the gentian-violet 
fails to dissolve. If diabetic urine, on the other hand, is treated in 
the same manner, the eosin will likewise dissolve, but a solution of 
the gentian-violet also occurs, and the entire specimen eventually 
assumes a violet color. 

Of late, Bremer has advised the use of Merck's gentian-violet B, 
or of methyl-violet 5B. The test is extremely simple : two well-dried 
test-tubes are filled to about one-half, the one with normal urine and 
the other with the urine to be examined. About 0.5 mgrm. of either 
of the above reagents is then placed upon the surface of the urine ; 
the tubes are kept in a warm place or immersed in warm water. 
On standing, streaks of blue gradually appear in both specimens, 
but on shaking the color disappears in the normal specimen, while 
the entire bulk of the diabetic urine assumes a blue or violet color. 
A reddish-purplish color is often observed in non-diabetic specimens, 
hut is of no significance. Bremer admits that doubtful results may 
be obtained with urines presenting a specific gravity below 1.014 or 
1.015, and that in such cases it may be impossible to distinguish 
non-diabetic from diabetic urine. He claims, on the other hand, 
that a positive result with a urine of high specific gravity is pathog- 
nomonic of diabetes, and that this may be obtained even at a time 
when the sugar has temporarily disappeared from the urine. 

The substance which gives rise to this peculiar reaction is un- 
known. Sugar in itself, as also acetone and diacetic acid, are not 
concerned in its production. The reaction of the urine also is unim- 
portant. Bremer is inclined to believe that in non-diabetic urines 
one of the coloring principles helps to render the urine refractory. 
As he says, colorless diabetic urines yield the most striking color- 
reactions, and especially those in which a greenish shimmer is 
apparent. 

On the whole, Bremer's observations have been confirmed so far 

1 L. Bremer, " Anilinfarbenproben d. Hams bei Diabetes," Centralbl. f. inn. Med., 
vol. xix. p. 307. T. B. Futcber, Pbila. Med. Jour.. 1S98. L. Bremer, " On the Chemi- 
cal Behavior of Eosin and Gentian-violet toward Normal and Diabetic Urines," N. Y. 
Med. Jour., 1897. 



452 THE URINE. 

as diabetic urine is concerned. Exceptions, however, occasionally 
occur even in cases of true diabetes, and, as Bremer admits, positive 
results are frequently observed in urines of a low specific gravity. 

The test is of interest, and may possibly be further modified so as 
to be of value in diagnosis, but as yet it would scarcely be warrant- 
able to draw definite conclusions from its occurrence, even when the 
specific gravity is high. 

Lactose. — Lactose may be found in the urine toward the end of 
gestation, but it occurs more especially in nursing-women in whom 
the flow of milk is impeded. It is generally stated, however, that 
lactosuria also occurs in nursing-women who have well-developed 
breasts, in the absence of any obstruction, and that the good qual- 
ities of a wet-nurse are indicated by a copious and persistent elim- 
ination of milk-sugar. Its presence may be inferred if a positive 
result is obtained with Trommer's and Ny lander's tests, while the 
phenylhydrazin and fermentation tests give negative results, although 
an osazon can be obtained from the isolated substance, and although 
lactose undergoes a certain form of alcoholic fermentation. 

Lemaire, who has recently investigated this subject, found that 
the urine of nineteen women examined in this direction apparently 
contained no sugar during the last twelve days preceding confine- 
ment (Trommer's and Nylander's tests), while a positive reaction was 
obtained with Trommer's reagent in two cases and with Ny lander's 
reagent in thirteen cases after confinement. The phenylhydrazin 
test was negative in all nineteen before and positive after confine- 
ment, when this was directly applied to the substance isolated according 
to Baumann's method. The percentage varied between 0.013 and 
0.438, and appeared to be uninfluenced by the act of nursing. 1 

Levulose. 2 — It is claimed that levulose is occasionally found in 
diabetic urines together with glucose. Such urines show a deviation 
to the left or none at all, while the other tests for sugar indicate the 
presence of a reducing substance. 

Maltose. — Maltose, together with glucose, was found in the urine 
of a patient supposedly the subject of pancreatic disease, associated 
with an acholic condition of the stools. Its recognition is practi- 
cally dependent upon the formation of its osazon and a determina- 
tion of the melting-point of the latter. 

Dextrin. 3 — In one case of diabetes dextrin appeared to take the 
place of glucose. It may be recognized by the fact that upon the 
application of Fehling's test the blue liquid first becomes green, 
then yellow, and sometimes dark brown. Traces of dextrin are 

1 De Sinety, Maly's Jahresber., 1874, vol. iii. p. 134. Hempel, Arch. f. Gynaek., 
1875, vol. viii. p. 312. Ney, Ibid., 1889, vol. xxxv. p. 239. F. Hofmeister, " Ueber 
Laktosurie," Zeit. f. physiol. Chem., 1877, vol. i. p. 101 (lit.). F. A. Lemaire, Ibid., 
1896, vol. xxi. p. 442. 

2 Seegen, Centralbl. f. d. med. Wiss., 1884, vol. xxii. p. 753. 

3 Reichard, Maly's Jahresber., 1876, vol. v. p. 60. 



CARBOHYDRATES. 453 

probably present in every urine, but cannot be demonstrated with 
the common tests. 

Laiose. 1 — Laiose has boon found in the urine of a diabetic patient. 
It is essentially characterised by the fact that on titration with 
Fehling's solution from 1.2 to L8 per cent, more sugar is indicated 
than by the polarimetric method. 

Pentoses. — To judge from recent observations, traces of pentoses, 
viz., xylose, arabinose, and rhanmose, may be found in every urine. 
Larger quantities were first observed by Salkowski and Jastrowitz, 
in the urine of a morphin habitue, in which the pentosuria alter- 
nated with glucosuria. A similar ease was reported by Real. Kiilz 
and Vogel found larger quantities in a case of diabetes ; and still 
more recently I >ial has reported two instances which occurred in 
apparently healthy individuals. A digestive pentosuria has also 
been described. Such urines reduce Fehling's solution and Nylan 1 - 
der's solution, and give rise to the formation of an osazon when 
treated with phenylhydrazin. The osazon, however, can be readily 
distinguished from that obtained from glucose, maltose, or lactose, 
etc., by the melting-point (159°-160° C). The fermentation test 
i- negative. Xylose and rhanmose turn the plane of polarization to 
the right, while arabinose is optically inactive. The presence of 
pentoses can be readily detected with Tollens ? orcin test. 

Tollens' Orcin Test. — A few granules of orcin are dissolved in 
4 to 5 c.c. of concentrated hydrochloric acid by the aid of heat, 
so that a slight excess is present. This solution is divided into 
two equal parts and allowed to cool. To one portion 0.5 c.c. 
of the urine to be examined is added, and to the other an equal 
amount of normal urine of the same specific gravity. Both speci- 
mens are placed in a beaker containing boiling water, when in the 
presence of pentoses a green color will first be observed at the top, 
which gradually extends throughout the mixture, while the normal 
specimen scarcely changes in color. In the presence of 0.1 per 
cent, a positive reaction is still obtained, which is especially marked 
if the urine has been previously decolorized with animal charcoal. 
The green pigment which results can be extracted by shaking with 
amyl alcohol, and on spectroscopic examination it gives rise to a 
well-defined band of absorption in the red portion of the spectrum 
near the yellow border. 

Tollens' phloroglucin test, in which phloroglucin is substituted for 
the orcin, and in which a deep-red color is obtained in the presence 
of a pentose, may also be used, but the reagent indicates the presence 
of glucuronates as well. 

Very curiously, the pentosuria persists even though no carbo- 
hydrates are ingested ; and there is evidence to show that pentoses 
are formed within the body. As a matter of fact, Hammarsten has 

1 Leo, Virchow's Archiv, vol. cvii. 



454 TEE URIXE. 

succeeded in demonstrating the presence of a pentose among the 
decomposition-products of a nucleo-glucoproteid which is found in 
the pancreas ; aud Blumenthal arrived at similar results in the case 
of various nucleinic acids which occur in the animal body. It is 
possible, on the other hand, that the pentoses may result from the 
metabolic products of glucose which are formed under normal con- 
ditions by a process of oxidation, and are then eliminated as such 
under still unknown influences. 

Aside from the traces normally present in the urine, pentosuria 
must be regarded as a metabolic anomaly, analogous to glucosuria, 
cystinuria, alkaptonuria, etc. 

Literature. — E. Salkowski u. M. Jastrowitz, " Ueber einebisber nickt beobacbtete 
Zuckerart lm Ham." Centralbl. f. d. med. Wiss., 1892, No. 19. E. Salkowski, " Ueber 
d. Pentosurie," Berlin, klin. Wocb., 1895, No. 17. F. Blumenthal, Ibid., No. 26 ; and 
Zeit. f. klin. Med., vol. xxxvii. p. 415. E. Kiilz u. J. Vogel, Zeit. f. Biol., N. F., 1896, 
vol. xiv. p. 189. E. Salkowski, " Ueber d. Vorkoinmen von Pentosen im Harn," Zeit. 
f. physiol. Chem., 1899, vol. xxvii. p. 507. 

Animal Gum. — Landwehr's animal gum, according to modern 
researches, is a constant constituent of normal urine, but is of no 
clinical interest. Of the chemical nature of the substance not much 
is known, but there is evidence to show that in all probability the 
body is a derivative of chondroitin-sulphuric acid. 



GLUCURONIC ACID. 

Glucuronic acid is derived from glucose, and constitutes an inter- 
mediary product of the normal metabolism of the body. In the 
urine it is found only in combination with certain fatty and aromatic 
alcohols, forming compounds which are related to the glucosides 
and are generally spoken of as the conjugate glucuronates. Such 
bodies have been observed in the urine following the ingestion of 
chloral, camphor, naphtol, oil of turpentine, menthol, phenol, mor- 
phin, antipyrin, etc., and traces may also be obtained from nor- 
mal urines. The normal glucuronates are undoubtedly compounds 
of glucuronic acid with phenol, paracresol, indoxyl, and skatoxyl. 
Their amount is exceedingly small, as the greater portion of 
these bodies is normally eliminated in combination with sulphuric 
acid. 

Of the quantitative variations of the normal glucuronates and 
their relation to disease, next to nothing is known. Their clinical 
interest centres in the fact that certain glucuronates are capable of 
reducing copper and bismuth in alkaline solution, and may thus be 
confounded with glucose. Such urines, however, do not undergo 
fermentation. The glucuronates turn the plane of polarization to the 
left, while glucuronic acid itself is dextrorotatory. Like the pen- 
toses, the glucuronates give a positive reaction with phloroglucin, 



URINARY PIGMENTS AND CHROMOQENS. 1V> 

while they do not react with orcin (see page 453). With the Ave 
acid phenylhydrazin forms crystalline compounds (see page 442). 

Lukkatikk. — H. Thierfelder, "Ueberd. Bildnng v. Glykuronsaure," etc, Zeit 
f. physiol. Chem., 1886, vol. x. p. 163; "Untersachungen fiber d. Glykuronsaure," Ibid., 
1887, vol. xi. ]>. 388. P. Mayer, "TJcber d. Ausscbeidung u. d. Nachweis d. Glyku- 
ronsaure," Berlin, kin . Woch., 1899, pp. 591 and (ilT. P. Mayer a.C. Neuberg, Zeit. f. 
physiol. Chem., 1900, vol. xxix. p. 256. 

INOSIT. 

According to Hoppe-Seyler, traces of inosit may be found in 
the urine under normal conditions. Somewhat larger quantities 
arc eliminated following the ingestion of large amounts of water, 
and for this reason possibly inosituria is notably observed in cases 
of diabetes insipidus, in diabetes mellitus, and in chronic intersti- 
tial nephritis. The substance is devoid of clinical interest. It is 
not a carbohydrate, but belongs to the aromatic series, and i-> 
commonly regarded as hexa-hydroxybenzol. Its formula is 
C 6 H 12 O — H 2 0. For methods of isolating the substance from the 
urine, the reader is referred to special works. 1 

URINARY PIGMENTS AND CHR0M0GENS. 

Under normal conditions urochrome and uroerythrin, to which 
latter the red color of urate sediments is due, are the only known 
pigments which occur preformed in the urine, while indigo-red and 
indigo-blue, derived from indoxyl sulphate and indoxyl glucuronate, 
may be artificially produced. In disease, on the other hand, various 
other pigments may be found, which occur in the urine either free or 
in the form of chromogens. Among the former mav be mentioned 
haemoglobin, metha?moglobin, haematin, ha?matoporphyrin, urorubro- 
hiematin, urofuscohsematin, urobilin, the biliary pigments, and melanin; 
while abnormal chromogens are met with following the ingestion of 
certain drugs, such as santonin, senna, rheum, iodine, etc., as also in 
cases of poisoning with carbolic acid, creosote, etc. The occurrence 
of some of these substances, such as the various forms of blood-pig- 
ment, the biliary pigments, and indigo, vi/.. indican, is of considerable 
clinical interest, while others again are of only minor importance. 

Normal Pigments. — Urochrome. — To the presence of this pig- 
ment, which appears to be identical with the normal urobilin of 
MacMunn, but which should not be confounded with the pathological 
urobilin of JaffS, the normal yellow color of the urine i- probably 
largely due. It is supposedly derived from bilirubin, which in turn is 
referable to haematin, and thus to the haemoglobin of the blood. From 
the bilirubin secreted into the intestinal tract it i- derived by a process 
of oxidation, and not of reduction, a- i- generally stated (Gautier). 
Such a transformation, according to our present knowledge, may, 
1 C. E. Simon. Physiological Chemistry, Lea Bros. & Co., 1901. 



±o<o THE UETSE. 

however, also occur directly, without the intervention of bilirubin, 
as uroehronie is found in the urine of dogs in which the bile is 
prevented from entering the intestinal tract by the establishment of 
a biliarv fistula. An increased amount is similarly found in cases 
in which resorption of large extravasations of blood is taking 
place — in short, whenever an increased destruction of red corpuscles 
occurs. Under the opposite circumstances — i. e., in conditions 
associated with a new formation of red corpuscles, as in certain 
forms of anaemia, chronic parenchymatous nephritis, diabetes, dis- 
eases of the bone-marrow, etc. — it occurs in diminished amount. 
Urochrome, moreover, is present in urobilin -tree feces, and even in 
those of infants with congenital atresia of the biliary ducts. 

In order to obtain urochrome from normal urine, this is acidulated 
with 1-2 grammes of dilute sulphuric acid pro liter, filtered, and 
saturated with ammonium sulphate in substance, when the flakes 
which are formed, if an excess of the salt has been added, are dried 
and treated with warm, slightly ammoniacal absolute alcohol ; the 
pigment is then obtained upon evaporation of the alcohol. 

An alcoholic solution of urochrome, like the urobilin of Jaffe, 
is said to exhibit a beautiful orreenish fluorescence when treated with 
ammonia and a few drops of a solution of zinc chloride ; but, 
unlike the latter substance, its acidulated alcoholic solutions present 
a broad band of absorption at F, which extends more to the left 
than to the right of this line, while the remainder of the spectrum 
is at the same time absorbed to the right end, from a point sorne- 
what to the left : -. Gam i, ;.n the other hand, states that by 
acting upon urochrome with acids he did not succeed in obtaining 
any product showing the urobilin band or yielding the well-known 
fluorescence with zinc chloride and ammonia. But a substance 
having both these properties was readily obtained by the action of 
aldehyde upon an alcoholic solution of the pigment. In a short 
time — shorter still when the liquid is warmed — an absorption-band 
appears like that of urobilin, and the tint of the solution deepens 
to a rich orange-yellow. With zinc chloride and ammonia a bril- 
liant green fluorescence appears, and the band is shifted toward the 
red, as that of urobilin is under like circumstances. The process 
can be stopped at this point by the simple addition of water, fir 
aldehyde has no such action upon aqueous solutions of urochrome. 
If, however, the action be allowed to continue, a further change 
ensues ; the liquid reddens, and a second band appears in the violet. 
The fluorescence can still be obtained with zinc chloride and am- 
monia, and both bands are shifted toward the red and are closer 

;>:her than before. The reaction with aldehyde, according to 
Garrod, affords a very delicate test for the presence of urochrome 
in alcoholic solutions. The product of the earlier stage, although 
it is not identical with urobilin, resembles that pigment quite as 



URINARY PIGMENTS AND CHR0M00EN8. 457 

closely as the products obtained from bilirubin and lnematin by the 
action of reducing agents ; but uo second hand is developed when 

aldehyde is added to an alcoholic solution of urobilin. 1 

!>y the action of potassium permanganate upon urobilin Riva 
and Chiodera 2 obtained a substance closely resembling urochrome, 

and a similar product is formed when an aqueous solution of uro- 
bilin containing ether is evaporated upon a water-bath. Neither 
product shows any absorption-band, and both behave as urochrome 
does when it is acted upon by aldehyde. 

Uroerythrin. — Uroerythrin is the pigment which imparts the red 
color to crystals of uric acid and the pink tint to urate sediments. 
Under strictly normal conditions it probably docs not occur in the 
urine, but it readily appears with the slightest deviation from 
health, and when present in larger amounts imparts a deep-orange 
color to the urine. Under pathological conditions it is seen espe- 
cially in cases of hepatic insufficiency, in which the liver, owing 
to a greatly increased destruction of red corpuscles, is unable to 
transform into bile-pigment all the blood-pigment which is carried 
to it. It also occurs when an absolute insufficiency on the part of 
the hepatic cells exists, so that the organ is not even capable of 
causing the transformation of a normal amount of haemoglobin. 
Uroerythrin is thus seen in notable quantities in cases of cirrhosis 
and carcinoma of the liver, in passive congestion resulting from 
heart-disease, in acute articular rheumatism, gout, pneumonia, 
malarial fever, erysipelas, spinal curvature, etc. In typhoid fever 
a marked excretion of uroerythrin is exceptional, and its occurrence 
has been associated with pulmonary complications. In nephritis 
it is seldom found in the urine, but Garrod cites an instance of 
pneumonia in ^vhich an abundant excretion of the substance accom- 
panied conspicuous albuminuria. 

In certain diseases, such as hepatic cirrhosis, the excretion of 
uroerythrin, as also of urobilin, is said to be much diminished 
when the patient is placed upon a milk-diet (Riva). 

Chemically, its relation to haemoglobin, luematoidin, and bilirubin 
is seen from the following analyses of the various pigments : 

C II N O S Fe 

Hemoglobin, 53.85 7.32 16.17 ... 0.39 0.43 

Ilrematoidin, 65.05 6.37 9.51 

Bilirubin, 67.83 6.29 9.79 16.79 

Uroerytbrin. 02.51 5.79 31.70 

When present in large amounts uroerythrin is readily recognized 
by the salmon-red color which it imparts to urinary sediments. 
Otherwise it is best to precipitate the urine with neutral lead acetate, 

1 A. E. Garrod, "The Bradshaw Lecture on tin- Urinary Pigments in Theii Patho- 
logical Aspects. •" Lancet, Nov. 10, 1!' ( ">. 

■-' Riva and Chiodera, Arch. ital. di Clin. Med., 1896, vol. xxxv. p. 505. 



458 THE URINE. 

barium chloride, or a similar reagent, when in the absence of uro- 
erythrin a milky-white precipitate is obtained, while a pale rose- 
colored sediment indicates the presence of the pigment in appreciable 
amounts ; a more pronounced rose color is produced if large quan- 
tities are present. In every case at least ten to fifteen minutes 
should be allowed to elapse before forming a definite conclusion, so 
that the sediment may have abundant time to settle. 

The pigment itself is unstable. Its solutions in alcohol or 
chloroform are rapidly decolorized by light, and even when kept in 
the dark quickly undergo change. Alkalies destroy the pigment 
readily, with the production of a green tint. Neutralization of the 
alkali does not restore the original color or bring back the absorption 
spectrum, which is characteristic, though ill-defined, consisting of 
two faint bands in green and blue, united by a fainter shading. 
One of these bands has the position of the urobilin band, but both 
alike disappear when the solutions are decolorized by light. The 
pigment is readily soluble in amyl alcohol and acetic ether (Garrod). 1 

Normal Chromogens. — The chromogens occurring in normal 
urine are indican, urohsematin, and an unknown chromogen which 
yields urorosem when treated with mineral acids. 

Indican. — It has been pointed out (see Sulphates) that the indol 
formed during intestinal putrefaction is oxidized to indoxyl in the 
blood ; this, entering into combination with sulphuric acid, is elimi- 
nated in the urine as sodium or potassium indoxyl sulphate, or 
indican, as represented by the equations : 



(1) C 8 H 7 N 


+ o 


= C 8 H 7 NO 


Indol. 




Indoxyl. 


(2) C 8 H 7 NO 


/OH 

+ so 2 < 

x OH 


/C 8 H 6 NO 
= S0 2 < + H 2 
X)H 


Indoxyl. 




Indoxyl suiphate. 


/C 8 H 6 NO 
(3) S0 2 < 

x OH 
Indoxyl sulphate 


+ Na 2 HP0 4 


/0 8 H 6 NO 
= S0 2 < + NaH 2 P0 4 
x ONa 
Indoxyl-sodium 
sulphate. 



Formerly it was thought that indican was also formed within 
the tissues of the body in the absence of putrefactive organisms. 2 
Further researches, however, have demonstrated that micro-organ- 
isms are always concerned in the production of indican, and that 
in health the large intestine is its sole source. Baumann, who 
succeeded in absolutely disinfecting the intestinal tract of a dog by 
means of large doses of calomel, thus observed that all traces of 

1 A. E. Garrod, loc. cit. A.Robin, Urologie cliniqiiedelaFievretyphoide, Paris, 1877. 

2 E. Salkowski, Ber. d. deutsch. chem. Ges., 1876, vol. ix. pp. 138 and 408. Bau- 
mann, Zeit. f. physiol. Chem., 1886, vol. x. p. 123. Senator, Centralbl. f. d. med. Wiss., 
1877, vol. xv. pp. 357, 370, and 388. 



URINARY PIGMENTS AND CHROMOOENS. 459 

indican, as also of phenol and paracresol, disappeared from the 

urine. According to Senator, moreover, indican does not occur 

in the urine of newly born infants which have not as vet 
received nourishment. This observation is a strong point in 
favor of Nencki's teachings that indol is a specific product of 
albuminous putrefaction in the presence of organized ferments, 
as putrefiable substances are here present, but no putrefactive 
organisms. Tuezek's observations on abstinence from food in 
cases of insanity, in which indican was observed in the urine only 
when albumins, though in minimal amounts, were ingested, also 
speak very strongly against Salkowski's theory. Finally, it has been 
demonstrated that in cases in which an artificial anus is established 
near the distal end of the ileum the conjugate sulphates disappear 
almost entirely from the urine, while they reappear in normal amount 
a- soon as the connection between the small and large intestines has 
been re-established. 1 

The amount of indican which is normally eliminated in the urine 
varies somewhat with the character of the diet. Jaffe 2 obtained 6.6 
mgrms. from 1000 c.c. of urine, as an average of eight obser- 
vations. The largest quantities excreted in health are found after a 
liberal indulgence in animal food, particularly the so-called red 
meats, while the smallest amounts are observed during a milk- or 
kefir-diet. By means of the latter article, indeed, the greatest dimi- 
nution in the degree of intestinal putrefaction may be effected in 
man. 

In pathological conditions an increased elimination of indican is 
observed : 

1. In all diseases which are associated with an increased degree 
of intestinal putrefaction. As there appears to be little doubt that 
this is largely regulated by the acidity of the gastric juice, an in- 
creased indicanuria, according to personal observations, is encountered 
when anachlorhydria or hypochlorhydria exists. It has been pointed 
out elsewhere that it is possible to form a fairly accurate idea of the 
amount of free hydrochloric acid in the gastric juice by an examina- 
tion of the urine in this direction. Large quantities of indican are 
thus eliminated in cases of carcinoma of the stomach, and exceeded 
<>nly by those observed in cases of ileus, so that this symptom, in 
my estimation, is of considerable value in differential diagnosis, 
and is one, moreover, which lias not received the attention it 
deserves. Exceptions to tin- rule are at times, though rarely, 
met with, for which it is, however, impossible to account at 
present. Large quantities of indican are also observed in cases of 
acute, subacute, and chronic gastritis. In the course of personal 

1 Nencki, Macfadyen u. Sieber, Arch. f. exper. Path. u. Pharmakol., 1891, vol. xxix. 

2 Jafft'. Centralbl.' f. d. med. Wiss.. 1872, vol. x. pp. 2, 481, and 497; and Virchow'fl 

Archiv. 1-77, vol. lxx. p. 72. 



460 THE URINE. 

observations in this direction I was impressed with the curious 
phenomenon that in cases of ulcer of the stomach, notwith- 
standing the simultaneous occurrence of hyperchlorhydria, an 
increased elimination of indican, contrary to what is usually seen in 
hyperchlorhydria referable to other causes, is quite constantly found. 
Possibly the existence of muscular atony which was noted in those 
cases may serve to explain this apparent incongruity, but it is as yet 
impossible to offer a satisfactory explanation of the phenomenon. 
Remembering the origin of indican, and the relation which the 
amount eliminated bears to the degree of intestinal putrefaction, it 
will be unnecessary to enumerate the long list of diseases in which 
an increased indicanuria has been observed, as it will be found that 
in the majority of these cases the indicanuria is merely an index 
of the condition of the gastric juice and the motor power of the 
stomach. 1 

2. It should be noted that in cases in which the peristaltic move- 
ments of the small intestine have become impeded, as in ileus, acute 
and chronic peritonitis, an increased elimination of indican will inva- 
riably take place, no matter what the state of the gastric juice may 
be. In such conditions, and especially in ileus, the largest quanti- 
ties are observed, a point which may be of decided value in differ- 
ential diagnosis, as diseases of the large intestine alone are never 
associated with an increase in the amount of indican. In simple, 
uncomplicated constipation increased indicanuria is not seen; and 
should an examination in such cases reveal the presence of more 
indican than normal, it will be safe to assume the existence of disease 
elsewhere, and especially of the stomach. 

3. As albuminous putrefaction may also take place within the 
body, an increased indicanuria is observed in cases of empyema, 
putrid bronchitis, gangrene of the lung, etc. ; but while in the con- 
ditions mentioned above the indol-producing organisms appear to be 
especially active, the elimination of phenol in the latter condition 
may be more pronounced at times than that of indican. Bearing in 
mind the points here set forth, I cannot agree with others in saying 
that the study of indicanuria possesses no importance from a clini- 
cal standpoint. I maintain, on the other hand, that an examina- 
tion of the urine in this direction is at least as important as the testing 
for albumin and sugar, and that points of decided importance, not 
only in diagnosis, but also in prognosis and treatment, may thus be 
gained. 

When indican is treated with hydrochloric acid it is decomposed 
into sulphuric acid and indoxyl ; should an oxidizing substance be 
present at the same time, indigo-blue, the blue coloring-matter of 
the urine, results : 

1 C. E. Simon, " Indicanuria," Am. Jour. Med. Sci. (full literature), 1895, vol. ex. 
n. 48. 



URINARY PIGMENTS AND CHROMOQENS. 461 

•VJI.NKSO, 20 ( 1 „lI 10 N,O. J •: -2I1KS0 4 . 
Potassium iinloxvl IndlgO-blue. 

sulphate. 

Indigo-blue in small amounts may be found free in the sediment 
of almost every decomposing urine, usually occurring in the form of 
small, amorphous granules, and more rarely in crystalline form. 
Urines have, however, also been observed which were blue when 
passed, or which turned blue as a whole upon standing. Such a 
phenomenon must be regarded as a medical curiosity. 

The blue pigment which may be obtained from urines has been 
variously described as Prussian-blue, urocyanin, cyanurin, Harn- 
blau, uroglaucin, choleraic urocyanin, but it has been shown 
to be indigo-blue, and derived from a colorless mother-substance 
which is present in every urine to a greater or less extent, and 
which has been named indican. This has been shown to be identi- 
cal with the uroxanthin of Heller and Thudiehum's choleraic uro- 
cyaninogen. 

Tests for Indican. — The urine of twenty-four hours is care- 
fully collected and a specimen taken for examination. A few cubic 
centimeters are then mixed with an equal volume of Obermayer's 
reagent, and shaken with a small amount of chloroform. Ober- 
mayer's reagent is a 2 pro mille solution of ferric chloride in concen- 
trated hydrochloric acid. 1 

Stokvis' modification of JafFe's test may also be employed. 2 To 
this end, a few cubic centimeters of urine are treated with an equal 
volume of concentrated hydrochloric acid, and two or three drops 
of a strong solution of sodium or calcium hypochlorite. The mixt- 
ure is shaken with 1 or 2 c.c. of chloroform as above. The indigo 
win eh is set free in this manner is taken up by the chloroform, and 
colors this blue to a greater or less extent, the degree of increase, as 
compared with the normal, being determined by the intensity of the 
color. Albumin need not be removed. Bile-pigment, which inter- 
feres with the reaction, is removed by means of a solution of lead 
subacetate, which is carefully added in order to avoid an excess. 
Urines presenting a very dark color may be cleared in the same 
manner. Potassium iodide, owing to the liberation of free iodine, 
will color the chloroform more or less of a carmine. For the sake 
of comparison, it is well to employ the same quantities of urine and 
reagents in every case, marked tubes being very convenient for this 
purpose. 

The method last described I have also found to be a fairly sensi- 
tive test for albumin, in the presence of which a well-marked cloud 
appears near the surface of the mixture and gradually extends 
downward. 

1 Obermaver. Wicn. klin. Woch., 1890, vol. iii. p. 17H. 

2 See Senator, Centralbl. f. d. med. Wiss., 1877. vol. xv. p. 257. 



462 THE L'RISE. 



Quantitative Estimation. — Wang's Jlethod. 1 — The method is 
based upon the decomposition of potassium indoxyl sulphate by 
means of concentrated hydrochloric acid and the oxidation to indigo- 
blue of the indoxyl which is thus formed. The indigo-blue is fur- 
ther transformed into indigo-sulphuric acid, and this titrated with 
a solution of potassium permanganate 01 known strength. The 
various changes which take place are represented by the following 
equations : 

(1)CHJS':\K- H ; = CJHA~.OH - ELKS0 4 . 
" Indieanf Indoxyl. 

(2) 2C 8 H 6 X.OH - 20 = C,H : J ; ; - 2H ; 0. 

Indoxyl. Indigo-blue. 

(3) CLA.NA - 2H,S0 4 = C H H 5 HSO- 2 S,0, - 2H,0. 

Indigo-blue. _:. :.:r: -5 :-.::_ -r:: _::. 

(4) BC^oXA - 4KMn0 4 - 6H£0 4 = 

Indigo-blue. - .:.,H : . : >" : ':>. - 2K : S0 4 - 4MnS0 4 — 6H,0. 

Reagents required : 1. A 20 per cent, solution of lead acetate. 

2. Obermayer's reagent. This is a 2 pro miile solution of ferric 
chloride in concentrated hydrochloric acid (sp. gr. 1.19 . 

3. Chloroform. 

4. Concentrated sulphuric acid. 

' , A mixture of equal parts of alcohol (96 per cent. ) 3 ether, and 

6. A concentrated solution of potassium permanganate — i. >:.. a 
solution containing about 3 grammes pro liter. The titration is 
conducted with this solution diluted in the proportion of 5 c.c. to 
195 c.c. of water. Its titre is ascertained before each titration by 
comparing it with a dilute solution of oxalic acid of known strength : 
for example, one containing 0.1 gramme of the acid dissolved in 100 
c.c. of water, as described on page 379. The amount of indigo-blue 
which each cubic centimeter will represent is ascertained by multi- 
plying the corresponding amount of oxalic acid by 1.04. 

Example. — Supposing that the permanganate solution is found of 
such strength that 1 c.c. represents 0.00014 gramme of oxalic acid : 
the corresponding amount oi indigo would be 0.0001-4 X 1.04 = 
0.0001 o gramme. 

3L:t: J. — The urine is first examined for indican. as described 

above. Should a very intense reaction be thus obtained, only 25 or 

?.c. are used for the quantitative estimation, while larger amounts 

are taken 200-500 c.c. if the reaction is of only moderate intensity 

or negative altogether. 

The urine is precipitated with lead acetate solution, care being 
taken to avoid an excess. A large and accurately measured 



- 



E. Wang. " Leber d. quantitative Bestiinmung d. Harnindikans.** Zeit. f. physioL 
n.. vol. xxv. p. 4 



Chera.. vol. xxv. p 



URINARY PIGMENTS AND CHROMOGEN& 463 

portion of the clear filtrate is treated in a separating funnel with an 

equal volume of Obermayer's reagent and extracted with chloroform. 
To this (Mid, 30 e.e. are added at a time and shaken for one minute. 
Two or three extractions are usually sufficient to remove the entire 
amount of indigo. The extract is placed in a small flask, and the 
chloroform distilled off. The residue is dried for a few minutes on 
a water-bath until traces of remaining chloroform have been re- 
moved. It is then washed with the alcohol-ether-water mixture to 
remove the reddish-brown pigment which is present together with the 
indigo-blue. The latter remains undissolved. After filtering off any 
particles of indigo that may be in suspension, through a small filter, 
this is dried and repeatedly extracted with boiling chloroform. The 
chloroform extract is filtered into the original indigo flask, the 
chloroform distilled off, the residue dried as before, and while still 
warm treated with 3 or 4 c.c. of concentrated sulphuric acid. The 
entire residue should be brought into solution by careful agitation. 
After standing for twenty-four hours the contents of the flask are 
poured into 100 c.c. of cold water; the flask is rinsed and the 
washings added to the solution. This is filtered once more and 
titrated with the permanganate solution. At first the blue color of 
the solution changes but little ; later it turns greenish, and finally 
becomes yellowish or entirely colorless — not red. As a rule, the 
end-reaction is quite distinct, but the titration requires experience. 
The best results are obtained when from 10 to 15 c.c. of the dilute 
permanganate solution are used. The resulting amount of indigo 
contained in the measured-off quantity of the first filtrate is then 
ascertained as described above. 

Example. — Amount of urine : 1780 c.c. 

The stock solution of potassium permanganate contains 3 grammes 
to the liter ; 1 c.c. = 0.00596 gramme of oxalic acid = 0.0062 
gramme of indigo. Diluted solution (5 : 200) ; 1 c.c. = 0.00015 
gramme of indigo. 300 c.c. of urine were precipitated with 25 c.c. 
of the lead solution; 250 c.c. of the filtrate, corresponding to 230.7 
c.c. of urine, treated with 250 c.c. of Obermayer's reagent. Extracted 
twice with chloroform. 4.3 c.c. of the permanganate solution were 
used in the titration = 0.00065 gramme of indigo, corresponding to 
0.005 gramme in the 1780 c.c, according to the equation 

230.7 : 0.00065 : : 1780 : x ; x = tl?! = 005. 

230.7 

Other methods for the quantitative estimation of indican which 
have heretofore been used, with the exception of the spectroscopic 
method of Miiller, are not only inaccurate, but, like this, too time- 
consuming and complicated to be of value to the practising physician. 
As a consequence almost all observers have based their conclusions 
upon an approximative estimation only. For practical purposes this 



464 THE URINE. 

is sufficient, and even Wang's method, though accurate and simple, 
will hardly find a ready entrance into the clinical laboratory, as it 
is still too time-consuming and too expensive for daily use. For 
scientific purposes, however, it may be recommended. 

Urohaematin. 1 — Urohaematin appears to be the chromogen of the 
red pigment of the urine, and is very likely closely related to in- 
doxyl. Little is known of its chemical composition or of its mode 
of formation. In all probability the red pigment which may be 
obtained from this substance is identical with other red pigments 
which have been described from time to time as occurring in the 
urine, such as that of Scherer, the urrhodin of Heller, the urorubin 
of Plosz, Schunk's indirubin, Bayer's indigo-purpurin, Giacosa's 
pigment, and also the indigo-red obtained by Rosenbach and Rosin 
by careful oxidation of the urine with nitric acid. 

Further investigations are necessary before this subject can be fully 
understood ; but bearing in mind the probable origin of urohaematin 
from indoxyl, it would possibly be best to speak of the red pigment 
as indigo-red. In accordance with the view that urohsematin is an 
indoxyl derivative, its clinical significance is similar to that of indican 
(which see). 

The presence in normal urine of urohsematin — i. e., a chromogen 
yielding a red pigment when treated with certain reagents — may be 
demonstrated by shaking urine with chloroform and decanting after 
several days, when the addition of a drop of hydrochloric acid to the 
chloroform extract will cause the appearance of a beautiful rose color ; 
this varies in intensity according to the amount of the chromogen 
present. 

The purplish color so often obtained in the chloroform extract 
when Stokvis' modification of Jaffa's indican test is employed is due 
to a mixture of indigo-blue and indigo-red. Indican, however, is 
generally present in larger amounts than urohaematin. In normal 
and, usually also, in pathological urines a red color is not obtained 
with the test mentioned. In a few isolated cases of ileus, peritonitis, 
and carcinoma of the stomach I have found more indigo-red than 
indigo-blue. 

The so-called " Reaction of Rosenbach " is a convenient test for 
indigo-red when this is present in increased amounts : the boiling 
urine is treated drop by drop with concentrated nitric acid, when in 
the presence of large amounts of indigo-red it assumes a dark Bur- 
gundy color, which sometimes takes on a bluish tinge when held 
to the light. Owing to a precipitation of the pigment the mixture at 
the same time becomes cloudy and the foam assumes a blue color. 
In well-marked cases the Burgundy color does not appear to be 
changed by the further addition of nitric acid, but will sometimes 
suddenly change from red to yellow when 10—20 drops of the acid 

1 G. Harley, Verhandl. d. physik. rued. Ges. z. Wiirzburg, 1855, vol. v. p. 1. 



URINARY PIGMENTS AND CHROMOOENS. 465 

have been added. This reaction Rosenbach ' regarded as symptomatic 

of various forms of severe intestinal disease associated with an 
impeded resorption throughout the entire intestinal tract. Ewald 2 
likewise noted this reaction in cases of extensive disease ol* the small 
intestine, in carcinoma of the stomach, and in acute and chronic 
peritonitis ; but he obtained negative results in carcinoma of the colon, 
stricture of the oesophagus, chronic diarrhoea, etc. Rosenbaeh's 
reaction should be viewed in the same ligld as a highly increased elimi- 
nation ofindican. I have met with the reaction in all conditions 
associated with greatly increased intestinal putrefaction, and, like 
Ewald, failed to note the reaction in a few cases of occlusion of the 
large intestine, in which an increased elimination of indican is like- 
wise never observed. 

Uroroseinogen. 3 — In addition to indican and urohaematin, still 
another chromogen, which yields a rose-red pigment when treated 
with mineral acids, appears to occur in normal urine, although in 
small amounts. Beyond the fact that the chromogen is not a conjugate 
sulphate, practically nothing is known of its chemical nature. The 
pigment, which has received the name urorose'm, or Harnrosa, 
appears to be identical with Heller's urophai'n. Urorosei'n is best 
demonstrated by treating 5—10 c.c. of urine with an equal amount of 
concentrated hydrochloric acid, and 1 or 2 drops of a concentrated 
solution of sodium hypochlorite, when in the presence of much 
indican the mixture assumes a dark-greenish, blackish, or dark- 
blue color, owing to the formation of indigo. AVhen the mixture 
is shaken with chloroform the supernatant fluid exhibits a beau- 
tiful rose color, which is due to the urorosei'n. This may now 
be extracted with amyl alcohol and separated from other pigments 
which are present at the same time, by shaking with sodium 
hydrate, whereby the solution is decolorized. Upon the addition 
of a drop or two of hydrochloric acid to the alcoholic extract the 
rose color reappears. Such solutions, however, soon become decol- 
orized upon standing. A rose-red ring, referable to this pigment, 
is also frequently obtained in pathological urines when the ordi- 
nary nitric acid test is employed. 

AVhile normally urorosei'n is obtained only in traces, appreciable 
amounts are often met with in pathological conditions associated 
with grave disturbances of nutrition, as in nephritis, diabetes, 
carcinoma, dilatation of the stomach, pernicious anaemia, typhoid 
fever, phthisis, and at times in profound chlorosis, etc. A vege- 
table diet also appears to cause an increase in the amount of the 
chromogen. 

1 Rosenbach. Berlin, klin. Woch., 1889, vol. xxvi. pp. 5, 490, and 520, and 1890, 
vol. xxvii. p. 585. 

2 Ewald, Ibid.. 1889, vol. xxvi. p. 95::. 

3 H. Rosin, Deutsch. raed. Woch., 1893, p. 51. 

30 



466 THE URnSE. 

Pathological Pigments and Chromogens. — Tie Blood-pigments. 

— The blood-pigments proper which niay occur in the urine have 
already been considered (^see page 412), and in this connection it 
will only be necessary to refer briefly to the occasional presence of 
hsematin, urorubroha?niatin, urofuscohseinatin, and hseniatopor- 
phyrin. 

H^matzs" is only rarely found. In order to demonstrate its pres- 
ence, the urine is rendered strongly alkaline with ammonia, filtered, 
and the nitrate examined spectroscopically. when the spectrum shown 
in Fig. 6 will be noted ; this may be changed into the spectrum 
represented in Fig. 7 by the addition of ammonium sulphide, 

URORUBROiLKiTATrs and tjboffsooh rRMATix were observed by 
Baumstark 2 in the urine of a case of pemphigus leprosus compli- 
cated with visceral lepra ; they appear to be closely related to 
hsernatin. The color of the urine in this case varied between 
dark red and brownish red, strongly suggesting the presence of 
blood. In order to separate the pigments, the urine was dialyzed 
and the contents of the dialyzer dissolved in sodium hydrate solu- 
tion. Upon the addition of hydrochloric acid to this solution a 
brown pigment separated out in flakes, while a second pigment 
remained in solution, imparting to it a beautiiul red color. Upon 
nitration the acid nitrate was again subjected to dialysis, when the 
red pigment likewise separated out. The former substance Baum- 
stark termed urorubroha?matin, and the latter nrofuseoha^matin. 

Uboh^iatoporphykix has the formula C 16 H^N.O p and is 
probably identical with the haematoporphyrin resulting from the 
action of sulphuric acid upon hsematin. MeMuun found a pigment 
answering the description of this substance in the urine in o - 
of rheumatism, Addison's disease, pericarditis, and paroxvsmal 
hemoglobinuria, which he termed uroasematin, but which in all 
probability was hematopoi-phyrin. Le Nobel found the same 
pigment in two cases of hepatic cirrhosis and in one case of crou- 
pous pneumonia. Others have likewise met with hsematoporphy- 
rinuria in various forms of hepatic dise;. — . as also in phtL^ - 
exophthalmic goitre, typhoid fever, and hydroa aestivalis; further, 
in association with intestinal hemorrhages, in cases of lead poison: 
and especially during long-continued use of sulphonal, trional, and 
tetronal. Xebelthau records the history of a female patient., the 
subject of congenital syphilis, who had passed dark-red urine as long 
as she could remember, and continued to do so while under observa- 
tion. Recent researches, moreover, have shown that in traces at least 
the substance is present in every urine. As regards the origin of 
these normal traces, the evidence is in iavor of the view that they 
are formed within the body during its normal metabolism, and 

1 F. Batraistark. Pfliga*s Arc-hav, 1874. veil. ix. p. 568. See, also, J. W. Sehmlfc^ 
Diss., Greifswald, 1874. 



URINARY PIGMENTS AND CHR0M00EN8, 467 

most likely in the liver, whence the substance is eliminated in the 
bile. A portion then escapes with the feces, while a similarly 
small amount is resorbed and eliminated in the urine. Increased 
amounts would accordingly suggest the existence of a hepatic 
insufficiency ; and, as a matter of fact, we find that actual anatom- 
ical lesions then not infrequently occur. Taylor and Sailer thus 
report that in their ease of sulphonal poisoning widespread degener- 
ation of the hepatic cells existed ; and Neubauer was able to isolate 
the pigment from the liver of rabbits to which sulphonal had been 
administered, while it was absent in all other organs. On the other 
hand, it is difficult to ascribe all the phenomena of such haemato- 
porphyrinuria to hepatic changes, seeing that changes of like degree 
may occur without conspicuous urinary abnormality, and there is 
still much that is obscure in this condition. 

Stokvis attributed the increased elimination of haematoporphyrin 
in cases of lead poisoning and following the continued use of 
sulphonal to the occurrence of hemorrhages into the intestinal 
mucosa, and suggested that the transformation of the haemoglobin 
into haematoporphyrin was favored by the sulphonal. But while 
intestinal hemorrhages may occur in the sulphonal cases, they are 
not always observed, and, as Garrod points out, Kast and Weiss, as 
also Neubauer, were unable to verify the recorded experiments of 
Stokvis, in which he claims to have obtained a small amount of 
haematoporphyrin when fresh blood was digested with pepsin-hydro- 
chloric acid and sulphonal at from 38° to 40° C. 

Urines which contain much haematoporphyrin arc usually dark 
red in color, but the shade may vary from a sherry or port-wine 
tint to a dark Bordeaux. It is noteworthy, however, that this color 
is not primarily due to the exaggerated degree of hsematoporphy- 
rinuria, but, as Hammarsten first pointed out, to other abnormal 
pigments which are but little known, but which are probably closely 
related to haematoporphyrin. As Garrod says, the removal of 
the haematoporphyrin from such urines causes little or no change 
of color, and when this pigment is added to normal urine until on 
spectroscopic examination bands of similar intensity are seen the 
change of tint produced is comparatively slight. In one such case, 
not due to sulphonal, he was able to isolate a purple pigment which 
differed in its properties from any known urinary coloring-matter, 
and to which the color of the urine in question was obviously in the 
main due. Neumeister also states that in sulphonal intoxication an 
iron-containing derivative of haemoglobin occurs in the urine, which 
presents a reddish-violet color and shows a single band of absorption 
in the blue portion of the spectrum immediately bordering on the green. 

Albumin is not present in uncomplicated cases of haematopor- 
phyrinuria, and the pigment itself does not give the albumin 
reactions. 



468 THE URINE. 

To test for hsematoporphyrin, the following procedure may be 
employed : 

Thirty c.c. of urine are treated with an alkaline solution of barium 
chloride. The precipitate, after having been washed with water and 
then with absolute alcohol, is extracted with ordinary alcohol acidu- 
lated with hydrochloric acid, by rubbing in a mortar. The solution 
thus obtained will present a reddish color in the presence of hsema- 
toporphyrin, and its filtrate yields the characteristic spectrum of the 
latter substance — i. e., four bands of absorption, of which two are 
broad and dark and two light and narrow. The former alone are 
characteristic, and frequently the only ones visible. One of these 
extends beyond D into the red portion of the spectrum, while the 
other is situated between b and F. Of the other two bands, one 
may be seen between C and D and the other between D and E y 
nearer E (Fig. 10). 

Gar rod's Method. — To demonstrate the presence of hsematopor- 
phyrin under normal conditions, or when small amounts only are 
present in the urine, Garrod's method should be employed. To this 
end, several hundred c.c. of urine (500—1500) are treated with a 10 
per cent, solution of sodium hydrate in the proportion of 20 c.c. of 
the alkali solution for 100 c.c. of urine. The precipitated phosphates 
are filtered off and thoroughly washed by repeatedly suspending 
them in water. Should the precipitate be of a reddish color, or if 
it shows the spectrum of hsematoporphyrin in alkaline solution 
when examined on the filter in the moist state, we may con- 
clude that much h^ematoporphyrin is present. In this case it 
is washed until the filtrate is colorless. If traces only are 
present, however, one washing must suffice. The precipitate is 
then treated with alcohol, which is acidified w r ith hydrochloric 
acid to such an extent that the phosphates are entirely dis- 
solved. The resulting solution should not exceed 15 to 20 c.c. in 
volume. This is then examined in a layer, of not less than 3 to 4 
cm. in thickness, for the spectrum of acid haBmatoporphyrin, using 
a spectroscope with slight dispersion. The solution is now rendered 
alkaline with ammonia and treated with an amount of acetic acid 
which just suffices to redissolve the precipitated phosphates. On 
shaking with chloroform this extracts the pigment, and the chloro- 
form solution then gives the spectrum of the alkaline hsematopor- 
phyrin, since organic acids do not change the pigment to the form 
which yields the acid spectrum. The residue which remains after 
evaporating the chloroform can finally be washed with water and 
dissolved in alcohol, when a nearly pure solution is obtained, which 
is comparable with a solution of hsematoporphyrin obtained from 
hsematin. 

Precautions : If a preliminary test shows that the urine con- 
tains but little phosphates, a small quantity of calcium phosphate 



URINARY PIGMENTS AND CHROMOQENS. 4Gi) 

in acetic acid Is added before the urine is rendered alkaline with the 
sodium hydrate solution. As haematin and chrysophanic acid arc 
also precipitated with the phosphates, their absence must be insured. 
For this reason the urine should contain no rhubarb or senna. 

In conclusion, it may be said that a chromogen of hsematopor- 
phvrin is also usually present in urines containing the free pigments, 
which probably explains why such urines gradually become darker 
on standing. 

Literatubb. — A complete account of the literature on hsematoporphyrinuria up 
to 1893 is given by B. Zoja, "Su gualche pigmento di alcune urine," etc., Arch. 
ital. di din. med., L893, vol. xxxii. p. 63. A. E. Garrod, loc. cit. ; and Cen- 
tralbl. f. inn. Med., 1897, No. 21. Taylor and Sailer, Contributions from the William 
Pepper Laboratory, Philadelphia, 1900, p. 120. 0. Neubauer, Arch. f. exper. Path. 
q. Pharmakol., 1900, vol. xliii. p. 155. B. .1. Stokvis, " Zur Pathogenese d. Hgemato- 
porphyrinurie," Zeit. f. klin. Med., vol. xxviii. p. 1. Kast u. Weiss, Berlin, klin. 
Woch., 1896, vol. xxxiii. p. 621. Hammarsten, "Skandin. Arch. f. Physiol.," 1891, 
vol. iii. }>. 31. Neumeister, Physiol. Chem., Jena, 1897. Nebclthau, Zeit. f. physiol. 
Chem., 1 -!»!•, vol. xxvii. p. 324. 13. Ogden, Boston Med. and Surg. Jour., 1898. 

Biliary Pigments. — Of the four biliary pigments, viz., bilirubin, 
biliverdin, biliprasin, and bilifuscin, the former alone is met with in 
freshly voided urines, while the others may form upon standing, 
being oxidation-products of bilirubin. The pigment is never found 
in normal urine, and its occurrence may be regarded as a positive 
symptom of disease. 

In health it will be remembered that bilirubin, C 10 H 18 jS t 2 O.„ 
formed in the liver from blood-pigment, is eliminated into the small 
intestine, in which it is transformed into hydrobilirubin and largely 
excreted as such in the feces, while a small portion is reabsorbed 
into the blood and eliminated in the urine as urochrome or normal 
urobilin. Whenever, then, the outflow of bile into the intestines 
becomes impeded bilirubin is absorbed by the lymphatics and elimi- 
nated in the urine. 

Among the numerous causes which give rise to eholuria under 
such conditions may be mentioned obstruction of the biliary ducts, 
and especially of the common duct, referable to simple swelling of 
its mucous membrane, as in the ordinary forms of catarrhal jaun- 
dice. It may also be due to the presence of a biliary calculus, to 
parasites, compression of the duct by tumors of the liver, the gall- 
bladder, the duct itself, and of neighboring structures, and particu- 
larly of the pancreas, stomach, and omentum. Whenever the 
blood-pressure in the liver is lowered, so that the tension in the 
smaller biliary ducts becomes greater than that in the veins, ehol- 
uria likewise results. The icterus occurring under these conditions 
has been termed hepatogenic icterus, in contradistinction to the form 
observed in cases in which the liver has cither totally or partially 
lost the power of forming bile, be this owing to the existence of 
degenerative processo affecting it< glandular epithelium, as in cases 
of acute yellow atrophy, or to destruction of red corpuscles 



470 THE URINE. 

going on so rapidly and so extensively that the organ is incapable of 
transforming into bilirubin all the blood-pigment which is carried to 
it. This occurs in pernicious ansemia, malarial intoxication, typhoid 
fever, poisoning with arsenious hydride, etc. Icterus neonatorum 
is probably to a certain extent also dependent upon the latter cause. 
To this form the term hcematogenic icterus has been applied. In such 
cases the occurrence of bilirubin in the urine can only be explained 
by assuming that a transformation of blood coloring-matter into 
bilirubin has taken place in the blood itself or in other tissues of the 
body. As a matter of fact, it appears to be generally accepted that 
such a transformation can actually occur outside of the liver, as 
the hsernatoidin which may be found in old extravasations of blood 
seems to be identical with bilirubin. On the other hand, however, 
the existence of a hematogenic icterus is positively denied, especially 
by Stadelmann. In accordance with his view, it may be demon- 
strated that in cases of pernicious anaemia, malaria, etc., the urine 
does not contain bilirubin, but usually urobilin. In cases of this 
kind which I had occasion to examine, bilirubin was never found. 
Further investigations are necessary to settle this question definitely. 

Usually the presence of biliary pigment may be recognized by 
direct inspection, as urines which contain this in notable amounts 
present a color varying from a bright yellow to a greenish brown. 
Any morphological elements which may occur in the sediment are 
stained a golden yellow, and the same color is imparted to the foam 
of the urine as well as to the filter-paper used in the filtration. At 
times, however, and particularly in cases in which the icterus is only 
beginning to appear, the presence of bilirubin is not infrequently 
overlooked, and urines containing urobilin in large amounts may be 
similarly mistaken for icteric urines. In doubtful cases, therefore, 
whether icterus exists or not, but in which the urine presents an 
intense yellow color, it is necessary to have recourse to chemical 
tests. A large number of these have been devised for the purpose 
of demonstrating the presence of bilirubin, all of which are fairly 
reliable. Only those will be described which I have examined 
myself and which are especially delicate. 

Smith's Test. 1 — Five to 10 c.c. of urine are placed in a test-tube 
and treated with 2 or 3 c.c. of tincture of iodine (which has been 
diluted with alcohol in the proportion of 1 : 10) in such a manner 
that the iodine solution forms a layer above the urine. In the pres- 
ence of bilirubin a distinct emerald-green ring is seen at the zone of 
contact. This test can be highly recommended, as it is exceedingly 
simple and not surpassed in delicacy by any other. 

Huppert's Test 2 — Ten to 20 c.c. of urine are precipitated with 
milk of lime (a solution of barium chloride is, perhaps, still more 

1 W. G. Smith, Dublin Med. Jour., 1876, p. 449. 

2 Huppert, Arch. d. Heilk., 1867, vol. viii. pp. 351 and 476. 



URINARY PIGMENTS AND CHROMOQENS. 471 

convenient), and the precipitate after filtering brought into a beaker 
by perforating the filter and washing its contents into the latter with 
a small amount of alcohol acidulated with sulphuric acid. The 
mixture is boiled, when in the presence of bilirubin the solution 
assumes a bright emerald-green color. Huppert's test is as delicate 
as is that of Smith, but is not so convenient for the needs of the 
practising physician. 

GmeHn's Test [as modified by Rosenbach). ] — The urine is filtered 
through thick Swedish filter-paper, when the latter is removed and 
a drop of concentrated nitric acid, which has been allowed to stand 
exposed to the air for a short time, is placed upon its inner surface. 
In the presence of bilirubin a prismatic play of colors will be seen 
to occur around the nitric acid spot. 

Gmelin's Test.' 2 — The urine is treated with nitric acid, which is 
carried to the bottom of the test-tube by means of a pipette, so as 
to form a layer beneath the urine, when a color-play, as already 
described (page 417), will take place at the line of contact between 
the two fluids ; the green color is the most characteristic. 

In this connection a few words may also be said of the occurrence 
in the urine of biliary acids and cholesterin. 

Biliary Acids. — These may usually be found in the urine whenever 
bile-pigment is present, so that their clinical significance is essenti- 
ally the same as that attaching to bilirubin. Their demonstration is, 
however, attended with such difficulties that the methods devised for 
this purpose may well be omitted at this place (see also page 228). 

Cholesterin. — Cholesterin has never been found in icteric urines, 
and is only rarely seen in other pathological conditions. It has 
been observed in cases of chyluria, fatty degeneration of the kidneys, 
diabetes, in one case of epilepsy, and in two cases of pregnancy, 
v. Jaksch has noted the presence of cholesterin crystals in a urinary 
sediment in a case of tabes and cystitis. I have found cholesterin 
crystals in the sediment in a case of acute nephritis. The urine 
was of a dark amber-color, cloudy, of an acid reaction, and a specific 
gravity of 1.028. In the sediment numerous hyaline and epithelial 
casts and some red blood-corpuscles were found. Giiterbook described 
a urinary calculus obtained from the bladder of a woman which con- 
sisted almost entirely of cholesterin (see also Feces). Langgaaid 
noted the presence of the substance in a case of chyluria. 8 

Pathological Urobilin. — This pigment should not be confounded 
with the urochrome or normal urobilin described above, to which 
it i> closely related, but from which it may be distinguished by 
means of the spectroscope. Gautier states that pathological urobilin 

1 Rosenbach, Central bl. f. d. med. Wiss., l-?<>, vol. \iv. p. 5, 

2 Tiedemann u. Gmelin, Die Verdauung oach Versuchen, Heidelberg, 1831, I. p. 79. 

3 v. Jaksch. Klinische Diagnostik, p. :;:;9. Glinski, Maly's Jahresber., 1894, vol. 
xxiii. p. 484. Langgaard, Virchow's Anhiv, vol. lxxvi. 



472 THE URINE. 

may be obtained from urochrome by submitting the latter to the 
action of reducing agents ; and, as I have already pointed out, Biva 
and Chiodera obtained a substance from urobilin by the action of 
potassium permanganate, which closely resembles urochrome. It is 
said to be identical with the stercobilin found in the feces, but differs 
from Maly's hydrobilirubin in containing a much smaller percentage 
of nitrogen, viz., 4.11, as compared with 9.22 (Garrod and Hop- 
kins). While its occurrence in the urine is essentially a pathological 
phenomenon, it is at times also met with in normal urine, and 
appears to be derived from a special chromogen, urobilinogen, from 
which it may be set free by the addition of an acid. Both urobilin 
and its chromogen are precipitated by saturating the urine with 
ammonium sulphate, and both are soluble in chloroform. Accord- 
ing to Maly, urobilin is formed by the reduction of bilirubin in the 
intestine, and is then in part resorbed and eliminated in the urine. 
Hayem, on the other hand, proposed the hypothesis that the sub- 
stance originates in a diseased or disordered liver, as bilirubin does 
in the same organ in health, and accordingly he regards the appear- 
ance of much urobilin in the urine as evidence of hepatic insuf- 
ficiency. Others, again, maintain that urobilin is formed in the 
tissues at large either by the reduction of bilirubin or directly from 
the blood-pigment. The first view is notably held by Kunkel, Mya, 
Giarre, and others, while the hematogenous theory is notably rep- 
resented by Gerhardt. Garrod discusses these various hypotheses 
at some length in his most interesting lecture on the urinary pig- 
ments in their pathological aspects, in which he personally inclines 
to the intestinal theory, as now held by Miiller, Schmidt, Esser, and 
others. In a work of this scope it would lead too far to discuss 
the various investigations which lend themselves in support of 
this view, and I can here quote only the following from Garrod' s 
paper : the chief seat of the formation of urobilin (for it is conve- 
nient to employ this term as including both pigment and chromogen) 
is undoubtedly the intestinal canal. This can only be gainsaid by 
denying the identity of the urinary and fecal pigments. The 
quantity normally present in the feces is far larger than that which 
enters the intestine with the bile (when a small amount is found), 
and there is strong evidence that the urobilin in bile is itself of 
intestinal origin. This being so, it is clear that theories other than 
the intestinal and its modifications merely attempt to trace a second 
source for the urobilin of the urine. It is equally clear that the 
substance from which the intestiual urobilin is formed is the bile- 
pigment. Under ordinary conditions the bile-pigment is destroyed 
in its passage along the intestine, and does not appear as such in 
the feces. In its place we find large quantities of urobilin, which 
in its turn disappears when occlusion of the common duct prevents 
the entrance of bile into the intestine. Again, when under certain 



URINARY PIGMENTS AND CHROMOQENS. 473 

morbid conditions the bile-pigment passes along the intestine unal- 
tered, urobilin is absent from the feces. However, the conversion 
of bilirubin into urobilin is DO mere process of reduction, but in- 
volves a much more radical change, with elimination of nitrogen. 

That the change is brought about by bacterial action there is much 
evidence to show. When bile is inoculated with fecal material and 
kept in an incubator a formation of urobilin rapidly takes place, and 
at the same time the bile-pigment diminishes, and ultimately dis- 
appears. 

From its frequent occurrence in febrile urines pathological urobilin 
has also received the name febrile urobilin. It is, however, also 
observed in many other conditions, and especially in cases present- 
ing the so-called hematogenic form of icterus, from which fact, 
indeed, and the usual absence of bilirubin at the same time, this 
form has been termed urobilin icterus. 

UrobUinuria has further been observed in certain hepatic diseases. 
In twelve cases of atrophic and hypertrophic cirrhosis v. Jaksch 
was able to demonstrate the presence of urobilin in every instance, 
a point which may at times be of considerable diagnostic importance, 
providing that other causes which are known to lead to urobilinuria 
can be eliminated. I have observed urobilin in a few cases of he- 
patic cirrhosis, chronic malaria, and pernicious anaemia, in all of which 
the skin presented a light icteric hue, and in which bile-pigment 
was absent from the urine. Unfortunately, an examination of 
the blood was not made, and I have hence not been able to con- 
firm the statement of v. Jaksch that bilirubin occurs in the blood 
in almost every case in which urobilin is present in the urine. 
Urobilin has also been noted in cases of carcinoma, scurvy, Addi- 
son's disease, haemophilia, in cases of retro-uterine hematocele, in 
extra-uterine pregnancy, following intracranial hemorrhages, etc. 
According to Bargellini, the degree of constipation in simple atony 
of the bowel is without influence upon the amount of urinary 
urobilin, but he states that in typhoid fever it causes an obvious 
increase; whereas disinfection or emptying of the large bowel pro- 
duces a notable diminution in the amount. 

Urines rich in urobilin usually present a dark-yellow color which 
i- -trough- suggestive of the presence of bilirubin ; even the loam 
in such cases may be colored, making the resemblance between the 
two pigments still more complete, v. Jaksch points out, however, 
that urines containing indican in large amounts often likewise 
] in -cut a very dark-yellow color, a statement with which my own 
observations are in perfect accord. In every case a more detailed 
chemical examination should hence be made. 

Gerhardt's Test. — If the urine contains much urobilin, which 
the color will indicate, 10—20 c.c. are extracted with chloroform by 
shaking, and the extract treated with a few drops of a dilute solu- 



474 THE URINE. 

tion of iodo-potassic iodide. Upon the further addition of a dilute 
solution of sodium hydrate the chloroform extract is colored a yellow 
or yellowish-brown, and exhibits a beautiful green fluorescence ; this 
is even more intense than that noted in the case of normal urobilin. 

Literature. — A. E. Garrod, loc. cit. A. E. Garrod and F. G. Hopkins, " On. 
Urobilin," Jour, of Physiol., 1893, vol. xxii. p. 451. Maly, Centralbl. f. d. nied. Wiss., 
1871, vol. ix. p. 849. Hayem, Gaz. hebdom., 1887, vol. xxiv. pp. 520 and 534 ; and Gaz. 
des Hop., 1889. vol. lxii. p. 1314. Kunkel, Virchow's Arcbiv, 1880, vol. lxxix. p. 655. 
Mya, Arch. ital. di clin. nied., 1891, vol. xxx. p. 101 ; and Lo Sperimentale, 1S96, vol. 1. 
p. 71. Giarre, Ibid., 1895, vol. xlix. p. 89, and 1896, vol. 1. p. 81. F. Muller, Schlesische 
Gesellscb. f. vaterland. Kultur, January, 1892. A. Schmidt, Yerbandl. d. XIII. Con- 
gress, f. inn. Med., 1895, p. 320. Esser, Untersuchungen iiber d. Entstehungsweise d. 
Hydrobilirubins. etc., Diss., Bonn., 1396. Bargellini, Lo Sperimentale, 1892, vol. xlvi. 
p. 119. v. Jaksch, Zeit. f. Heilk., 1395, vol. xvi. p. 48. D. Gerhardt, Zeit. f. klin. Med., 
1897, vol. xxxii. p. 313. 

Spectroscopic Examination. — This is necessary when Ger- 
hardt's test yields a doubtful result. The urine is then best examined 
as follows : 50 c.c. of urine are extracted in a separation funnel with 
amyl alcohol, which takes up both the pigment and its chromogen. 
After standing for several hours the urine is allowed to flow away, 
by opening the stopcock, when the alcoholic extract is decanted from 
above, and is treated with a concentrated alcoholic and ammoniacal 
solution of zinc chloride. In the presence of urobilin the liquid 
shows a beautiful fluorescence, and on spectroscopic examination a 
single band of absorption is seen between b and F. In acid solu- 
tions, on the other hand, a single band is likewise obtained between b 
and F, but this extends to the right beyond F, and is much darker. 
Should the urine contain much urobilin, its special extraction is not 
necessary. In such an event the acid urine shows the acid spectrum, 
while the alkaline band is obtained after the addition of ammonia 
(see also Bang's Test). 

Melanin and Melanogen. — In cases of melanotic disease it has been 
repeatedly observed that the urine, which usually and probably 
always presents a normal yellow color when voided, gradually 
becomes darker upon exposure to the air, and finally turns black. 
This phenomenon indicates without a doubt that such urines contain 
a chromogen, melanogen, which, upon oxidation, yields the black 
pigment noted in these cases, viz., melanin. As yet, it has not been 
possible to isolate this substance in pure form, and it is, indeed, not 
definitely determined that the black color in such urines is refera- 
ble to a single pigment. Such urines generally contain melanin and 
its chromogen in solution ; deposits of melanin granules by them- 
selves are only occasionally seen, and are not characteristic, as they 
may also be found in cases of chronic malarial intoxication, etc., 
when they may, indeed, be met with in the blood, constituting the 
condition spoken of as melanazmia. 

While the occurrence of melanin in the urine is probably indica- 
tive in most cases of the existence of melanotic tumors, it should 



URINARY PIGMENTS AND CHROMOQENS. 475 

be stated that x\u< symptom cannot be regarded as pathognomonic, 

as it may be absent in the case of melanotic tumors, and present in 
wasting diseases and inflammatory affections, and may at times, 
though very rarely, even be associated with the presenceof non-pig- 
mented growths. Nevertheless, its occurrence should always be 
regarded with suspicion, and, taken in conjunction with other symp- 
toms, will often lead to a correct diagnosis. 

Urines which darken upon standing should be subjected to the 
following tests : 

1. A tew cubic centimeters of urine are treated with bromine- 
water, when in the presence of melanin or melanogen a precipitate 
is obtained, which is yellow at first, but gradually turns black. 

'2. Ihe addition to melanotic urine of a few drops of a strong 
solution of ferric chloride will cause the appearance of a gray color, 
which is imparted to the precipitate of phosphates occurring at the 
time. 

Literature.— T. H. Eiselt. "Die Diagnose d. Pignientkrebses (lurch d. Harn," 
Prag. Vierteljabrschr. f. praktische Heilk., 1858. iii. p. 190. and 1862, vol. iv. p. 26. 
Senator, " Ueber sehwarzen Urin," Charite Annal.. 1891. Huppe-Sevler. Zeit. f. 
physiol. Chem., 1891, vol. xv. p. 179. F. Grohe, " Zur Gesch. d. Melanaemie," Vir- 
ehow's Archiv. 1861, vol. xx. p. 306. 

Phenol Urines. — The development of a dark-brown or black color 
upon standing is not always due to the presence of melanin, as a 
similar appearance may be noted in cases of poisoning with carbolic 
acid, following the ingestion of salol, hydrochinon, pyrocatechin, 
salicylic acid, etc., in large amounts. The color in such cases is due 
in all probability to the presence of various oxidation-products of 
hydrochinon, and in the last instance possibly to the so-called 
humin-substances. 

The test referred to above will prevent confusion as to the origin 
of the color as far as melanin is concerned, and with the his- 
tory of the case given, moreover, further chemical examination is 
generally unnecessary. In suspected cases of carbolic acid poison- 
ing, however, the mineral as well as the conjugate sulphates should 

be quantitatively determined, when the factor — (see Sulphates) 

will be found greatly diminished. If at the same time other fac- 
tor-, which might cause a greatly increased elimination of conjugate 
sulphates, can be excluded, the diagnosis of poisoning with carbolic 
acid or one of its derivatives may be inferred. Salol and salicylic 
acid may be recognized from the fact that such urine- when treated 
with a solution of ferric chloride develop a marked violet color which 
<\<h'< not disappear on standing. The reaction thus differs from that 
obtained with diacetic acid (see also page 489). 

Alkapton. — Urines are at times, though very rarely, ^een which, 
like the phenol urines, turn dark on standing, but in which the 



476 THE URINE. 

change in color is neither referable to the presence of phenol or its 
derivatives, nor to nielanin. Such urines are of a normal color when 
passed, but gradually turn reddish brown upon exposure to the 
air. Treated with a small amount of alkali, this change occurs 
almost immediately. Fehling's solution is reduced on the applica- 
tion of heat, while bismuth is not affected. Ammoniacal silver 
solution is reduced in the cold, and a temporary bluish-green color 
develops when the urine is treated with a ferric salt. The fermenta- 
tion test is negative, and examination with the polarimeter shows 
that the substance in question is not glucose. 'With phenylhydrazin 
no osazon is formed. 

Bodeker, who first observed a urine of this kind, termed the sub- 
stance giving rise to the reactions just described alkapton, and sub- 
sequently expressed the belief that his alkapton might possibly have 
been pyrocatechin. Subsequent investigators succeeded in isoL ting 
substances from such urines which have been variously termed pyro- 
catechuic acid, urrhodinic acid, glucosuric acid, uroleucinic acid. 
uroxanthinic acid. Baumann and Wolkow later were able to iso- 
late homogentisinie acid in pure form from the urine of such a case, 
and expressed the belief that some of the substances obtained by 
previous observers were in reality the same. Since that time this 
acid has also been found by Ogden. Stange, Stier. and others. There 
is reason to believe, however, that the reaction is not always du 
one and the same substance. 

Of the origin of alkapton very little is known. Baumann ex- 
pressed the opinion that homogentisinie acid might be derive'! : 
tyrosin, and that the condition is referable to the activity of spe< 
micro-organisms in the upper portion of the intestines. Others 
oppose this view and regard alkaptonuria as evidence of a definite 
metabolic anomaly taking place in the tissues of the body. Tyrosin. 
moreover, belongs to the para-series, while homogentisinie acid is 
an ortho-compound, and has never been encountered in the f& 
Culture-experiments from ordinary stools and from those passed 
after the administration of castor oil have yielded negative results. 
no alkapton acid being formed by culture in either broth, meat-juice, 
or ty rosin-broth (G-arrod). Embden also observed that when an 
alkaptonuria- individual took homogentisinie acid by the mouth a 
far larger proportion appeared in the urine than when the same 
substance was administered to a healthy individual. However this 
may be, alkaptonuria can scarcely be regarded as a pathological phe- 
nomenon, although it may occur in disease. It has thus been ob- 
served in connection with glucosuria, acute gastro-intestinal catarrh, 
phthisis, acute miliary tuberculosis, in one case of brain tumor, 
carcinoma of the prostate, etc. More frequently the condition is 
accidentally discovered by life insurance physicians in apparently 
healthy individuals, and has repeatedly been confounded with glu- 



URINARY PIGMENTS AND CHROMOQENS. 177 

oosuria. Like cystinuria and diaminuria, it may occur in families ; 
it may appear in childhood, and persist through years, and perhaps 
a lifetime. 

The amount of homogentisinic acid eliminated in the twenty-four 
hours is variable, but is usually large. Baumann thus found an 

average elimination of 4.(5 grammes, which in one case could be 
increased to 14 grammes by the administration of tyrosin. Larger 
quantities are also obtained after a liberal diet of meats. Phenyl- 
acetic acid, phenyl-amido-acetic acid, and benzoic acid, on the 
other hand, do not cause an increased excretion of homogentisinic 
acid. 

To isolate homogentisinic acid from alkapton urines, and to deter- 
mine its amount, Baumann's METHOD may be employed. The col- 
lected urine of twenty-four hours is acidified with 250 c.e. of a 
1_! per cent, solution of sulphuric acid and extracted three times 
with an equal volume of ether. The ethereal extract is evaporated 
to a syrup. The crystals which separate out on standing air dis- 
solved in 250 c.c. of water. This solution is brought near the boil- 
ing-point, and is then treated with 30 c.c. of a neutral lead acetate 
solution (1 : 5) and rapidly filtered. In the filtrate the lead salt 
crystallizes out in transparent needles and prisms. This is then 
decomposed with hydrogen sulphide and the filtrate carefully evap- 
orated on a water-bath until the fluid begins to darken, when it is 
further concentrated in the vacuum to the point of crystallization. 
The resulting prismatic crystals are almost colorless and transparent. 
They melt at a temperature of 146.5°-147° C, and are readily 
soluble in water, alcohol, and ether, and are almost insoluble in 
chloroform, benzol, and toluol. A solution of the acid, which may 
thus be isolated in pure form, presents the same characteristics as 
the urine from which it was obtained. 

The following method, suggested by Garrod, may also be employed, 
and has the advantage of greater simplicity. 

Garrod's Method. — The urine itself is heated nearly to boiling 
without any preliminary treatment, and for each 100 c.c. of urine at 
least 5 or 6 grammes of solid neutral lead acetate are added. 

As soon as the acetate is dissolved, the bulky gray precipitate 
which forms is removed by filtration, and the filtrate, which lias a 
pale-yellow color, is allowed to stand for twenty-four hours in a cool 
place. If the urine be very rich in homogentisinic acid, or if the 
flask containing it be placed upon ice, minute acicular crystals, which 
are almost colorless, quickly form ; but as a rule crystallization 
does not commence until several hours have elapsed. The crystals 
are then much larger, are grouped in stars or rosettes, and are more 
deeply colored. 

In summer weather it would probably be desirable to start the 
crystallization by artificial cooling ; but although the process is greatly 



478 THE URINE. 

accelerated at a low temperature, the total yield is not materially 
increased. 

If formation of the crystals be long delayed, the liquid may be 
warmed again and more lead acetate added. 

After the lapse of twenty-four hours crystals cease to form, even 
when the liquid is placed upon ice. 

The crvstalline product so obtained is lead homogentisinate. "When 
the crystals are dissolved in hot water the solution assumes a deep- 
brown color with alkalies : it reduces Fehling's solution readily with 
the aid of heat, and yields a transitory deep-blue color with a 
dilute solution of ferric chloride. From the lead salt free horuo- 
gentisinic acid may be obtained by decomposing it with hydrogen 
sulphide. 

Literature.— Bodeker. Annal. d. Chemie a. Pharruakol., 1361, vol. cxvii. p. 93. 
Baumaim u. Wolkow. Zeit. f. physiol. Cheui.. 1891, vol. xv. p. 22s. Stier. Berlin, klin. 
Woch., 1898, vol. xxxv. p. 135. Embden, Zeit. f. physiol. Chem., 1393, vol. xvii. p. 182, 
and vol. xviii. p. 304. Ogden, Zeit. f. physiol. Chem., 1395. vol. xx. p. 230. Futcher, 
X. Y. Med. Jour.. 1395, vol. lxvii. p. 69. G-arrod, Jour. Physiol., 1899, vol. xxiii. p. 
512 ; and Med.-Chir. Trans. Boyal Med. and Chir. Soc, vol. lxxxri. p. 367. 

Blue Urines. — Blue urines are sometimes seen, the color of which 
is due to indigo formed from urinary indican, in all probability 
within the urinary passages. Their occurrence can only be regarded 
as a medical curiosity. Formerly, when indigo was employed in 
the treatment of epilepsy, blue urines were frequently seen. At the 
present time, when methylene-blue is occasionally used in the treat- 
ment of malaria and chyluria, this pigment is found in the urine. 

Green Urines. — Green urines have also been described ; the cause 
of the color, however, has not been definitely ascertained. 

Pigments referable to Drugs. — Certain drugs may also cause 
changes in the normal color of urine, and in doubtful cases inquiry 
in this direction should be made. It has been pointed out that car- 
bolic acid, hydrochinon, pyrocatechin, and salol cause the appearance 
of a dark-brown color, and that after the administration of indigo 
and methylene-blue blue urines are voided. Santonin, rheum, and 
senna color urines a bright yellow, so that they may resemble icteric 
urines in appearance. The yellow color in such cases is changed to 
an intense red by the addition of an alkali, and, if ammoniacal fer- 
mentation is going on at the same time in the bladder, the patient 
may believe himself to be suffering from haematuria. The red color 
thus produced is due to the action of the alkali upon chryso- 
phanic acid. When urines containing copaiba are treated with 
hvdrochloric acid a red color results, which changes to violet upon 
the application of heat. During the administration of potassium 
iodide, or the use of iodine in any form, a dark mahogany color is 
obtained when the urine is treated with nitric acid. In doubtful 
cases Stokvis' modification of Jaffe's test for indican should be em- 



PLATE XVII, 




r~n 



Ehrlieh's Diazo-Reaetion, as modified by the author. 
The orange color in the lower portion of the test tube may 
be obtained in any urine; the dark carmine ring indicates 
the presence of the reaction in a well-pronouneed degree; 
the colorless zone above is intended to indicate the am- 
monia that has been added. 



URINARY PIGMENTS AND CHROMOGENS. 479 

ployed, when in the presence of an iodide the chloroform assumes a 
beautiful rose-red color. 

For the detection of other drugs and poisons in the urine the 
reader is ret erred to special works. 

Ehrlich's Reaction. — Under certain pathological conditions, and 
especially in typhoid fever, a chromogen maybe present in the urine, 
which, when treated with diazo-benzene-sulphonic acid and ammonia 
imparts a distinct red color to the urine, varying from eosin to a 
deep garnet-red (Plate XVII.). This reaction, which is generally 
spoken of as Erhlich's reaction, or the diazo-reaction, was at one 
time regarded as pathognomonic of typhoid fever. Subsequent 
examinations, however, have shown that it may also be present in 
other diseases. Michaelis, who has made an exhaustive study of 
this question, divides into four groups the diseases in which the reac- 
tion has been observed. In the first group, comprising diseases of 
the nervous system, chronic diseases of the heart and kidneys, 
malignant tumors, etc., the reaction is rarely seen. When present, 
it usually indicates a secondary infection. The second group in- 
cludes those diseases in which the reaction is almost always present, 
namely, typhoid fever and measles. In the diseases of the third 
group it is often, though not invariably, observed. Under this 
heading are classed scarlet fever, erysipelas, pneumonia, diphtheria, 
pyaemia, acute miliary tuberculosis, etc. The fourth group comprises 
pulmonary tuberculosis, and includes acute caseous pneumonia. 

The value of Ehrlich's reaction in typhoid fever was at first overesti- 
mated, but is at present certainly underestimated. I have personally 
studied this problem with great care, and after many years' experience 
maintain, as I did years ago, that the test is a most important 
diagnostic aid in the disease in question. As a general rule the 
reaction is present as early as the fifth or sixth day, and may persist 
into the third week ; it then disappears, but may reappear when a 
relapse occurs. Excepting in children, its absence from the fifth to 
the ninth day usually indicates a mild case. This rule, however, is 
not without exception, and I have seen a case of typhoid fever in 
which notwithstanding exceedingly high temperatures (106.5° at f> 
a. M.) the reaction was not obtained until the beginning of the 
third week, and then persisted for only a few days. When the 
reaction is continuously present after the third week I am inclined 
to suspect acute tuberculosis. 

Of late much attention has been paid to the occurrence of Ehrlich's 
reaction in pulmonary phthisis. As a result of his investigations 
Michaelis concludes that its presence in such cases indicates either 
that the process is very extensive or that it will progress very rap- 
idly, and that the prognosis is grave. A cure, he thinks, is impos- 
sible, and improvement, if any, only temporary. His conclusions 
in the main coincide with the results obtained by others, but it must 



m 



— ~ _ _~ .: ~ 

, ::, . .: lin^ rrz; — 

::ii jiref rl= : :: F.Vli: 
r: - 1= --t : — : : - it. v.:. . 
:~: 11:: :_:- i- i . : 1111 



A= :_ .t ~::i":::::: n : :_:i.:.\;" i:-: i~>~. __:: 7 .. : t .- :- 

:• _:±::i.. i: >:•-.— Hit.::;: >.- ~""T_ ■ ...; l:..: . :.: ~ ._::'_. 

~_.ti: t: nil'... ""::_: i_.it: : - . :: . in . :.•:::: -:.!-:. r: — i>- i: n.i 
::h_it::i .: ."..:: : : -:-i:t1t--:t _: ni : . .: . :- :- ~i_:~z .7 t_t 
t-" : .:.-: . 1- 

: ;• :\ - -;. = Xic: -fM«v 
. :. : z. -hso^c^ -ha 

>0 : H 60/ 

E - . - ..'_ : ■ _ ' ?..rr-"'.-~ v.- : : - 
j:i. ....„..::._ __....!.: • . . i 

This is ike active principle in the mixture employed. 

_ :_t: ;. :_T'..:i. "..-:_. ■' .: . ..: — :_- \- : — • .. -1: .1 : - n-rii-: !_.:... : - 



gramme for each 100 c-.e. The other is a 0.5 per cent, solution of 

Tin t~: -:_::: :i-::t ziix -e*I 111.11 e 1 .. :- . ~ " - ; : : t :-:i._: :i :_-r :r> 

t: 1 : - :. 1. A :i~ :. :-.n_iiiiii.i.r; :: 11:11 ::- 11 in 

.- . 11 : .:.:_ --:_■.„_., : mi- i:..:i ii_i mixm: - - 1-1 

i:::i . :.i..„ 11 - - ■;-__ iTiiziinimi _■■..::-. Till- :- -: 

iT ""t-... t. 1 — .:~z :':.t -:ii^ 1: ii_i 1::.-: -: :- 1 ::in 1 LijtI 

1 .": :_t 111:111:1 A. tit 1.1:1: 1 :: :_ 1 i~" : 1 1: ... ; : : . :^i 11^ 



TllrSrllr 1 It', V ~_ \Z 1- TllTr.". Till. lUli: 

- :: •_ -: - \ _- rnn-i: : I: 

tafed and Kite .reaction is positive, the foam 

. - . v .: 

n"i:i •'"::-: i .eiiiifA -,ilni"n :•.'_:: :« :' i:: 
of the chromogen axe present. Carried o 
question will arise as to the presence or a 

Z.. :.:.:. -i: :• - :':.;. : •:::'. :; ji-r--::: 
.ilkilizii.-:'.: it in:: ir. ii : It 1.11 : i« :":_:? — i: 
1:1 ri?r: -'-7 -i:-:ii:i> i ; -i-n .in: :":ii- 
iii : . :-:i.:i:i:-"T^:::::i::ii..i 



URINARY PIGMENTS AND CHROMOOENS. 



481 



rested 



TVphoid lever 

Malarial fever 

Tetanus 

Acute miliary tuberculosis . . 

Joint tuberculosis 

Pulmonary tuberculosis . . . 

Septicaemia 

Ulcerative endocarditis . . . 

Secondary syphilis 

Erysipelas 

Scarlatina 

Measles 

Carcinoma 

Pneumonia 

Rheumatism, chronic .... 

Rheumatism, acute 

Diphtheria 

Diarrhoea 

Appendicitis 

Albumin aria of pregnancy* . 

Chronic nephritis 

Cystitis 

Urethritis, specific 

Oxaluria and lith?emia . . . 

Pleurisy 

Pyaemic abscess of lung . . . 
Tuberculosis of prostate . . . 
Necrosis of long bones . . . 

Rotheln 

Syphilis (third stage) .... 

Alcoholic neuritis 

Hysteria 

Epilepsy 

Leg ulcer, varicose 

Fractures, long bones .... 

Fracture, skull 

Burns, severe 

Gunshot wounds, aseptic . . 
Morphin poisoning .... 

Sciatica 

( irrhosis, hepatic 

Simple enteritis 

Angioneurotic oedema .... 

Endometritis 

Pericarditis 

Meningitis 

Vulvitis and vaginitis, specific 
Orchitis, gonorrheal .... 
Valvular heart-disease . . . 
Quinsy and tonsillitis .... 

Normal urines 

Varicella 

Typhoid relapse 

( rastric ulcer 

Acute bronchitis 

Chronic constipation .... 



Total 
Number. 



64 
4 
2 



Reaction. 



4 
16 

4 

1 
4 
2 
3 
2 
4 

11 

10 
5 
3 
4 
3 
6 

19 
2 
7 

11 
5 
1 
3 
2 
1 
5 
3 
6 
2 
7 
5 
2 
2 
2 
1 
3 
2 
3 
2 
3 
1 
1 
2 
1 
7 
3 

30 
1 
3 
2 
3 
7 
315 



Present. 

Hi 1 







95 per cent. 



31 



482 THE URINE. 

more importance to the salmon color obtained upon copious dilution. 
With normal urines this is never obtained, and it can still be seen 
"when inspection ol the fluid in the test-tube would leave in doubt. 

The older method oi Ehrlich I have abandoned, as the test 
just described is simpler, and. in mv experience, just as reliable. 
He advised the addition of about 50 c.c. of absolute alcohol to 10 
c.c. of urine, subsequent nitration, and examination of the flit: 
as just described. 

me states that if 1 part of the sodium nitrite solution is 
It LOO instead of 4 n pan- of the sulphanilic acid solution, a 
. >:::v : reaction is no longer obtained in cases of croupous pneu- 
monia and of pulmonary tuberculosis, while in typhoid fever the 
reaction occurs with the same intensity. It is thus possible that the 
test may be still further modified, and become even more valuable. 
On j age 481 are given some : :he results which Greene obtained 
with this method. 

While in the absence of the chromogen, as I have already stated. 
a more or less pronounced orange color is usually obtained, excep- 
tions have been noted. Ehrlich thus records that in urines contain- 
ing biliary coloring-matter an intensely dark, cloudy discoloration 
occurs at times, which upon boiling is changed to a well-marked 
reddish violet. In rare instances of ulcerative endocarditis, her 
: scess, and intermittent fever. Ehrlich farther observed an intense 
yolk-yellow color, which was even imparted to the foam. 

Of interest is the observation of Burghart. that after the adminis- 
tration of tannic acid, gallic acid, and certain iodine preparations, 
Ehrlich \s reaction disappears from the urine. But. as Burghart 
himself suggests, it is likely that this inhibitory effect is not exerted 
upon the diazo-forming substance, but upon the reagent employed. 

Litebatuez. — Ehrlich. Zeit. f. klin. Med.. 1552. vol. v. p. 285; Charite Anna!.. 
: — '. vol. viii. p. 25. and 1556. vol. xL p. 139. Goldschmidt, Munch, med. Woeh.. 
1886, vol. xxxiii. p. 35. Eumnevex. Corresp. Blatt. f. Schweizer Aerzte. 1890, vol. xxvi. 

sue, Med. Beeord. Nov. 14, 1896. C E. Simon. Johns Hopkins' Hosp. Ball.. 18 
J. Friedenwald. N. Y. Med, Jour.. 1593. M. Miehaelis, Berlin, klin. Woeh.. 1900. p. 
274 and Dentsch. med. Woeh.. 189S [ 156. J. B. Arneill, Am. Jour. Med. BcL, 
1900, p. 296. 

CONJUGATE SULPHATES. 

In addition to indoxyl (see Indican), skatoxyl. phenol, para-: 
and pyrocatecltin occur in the urine iu combination with sulphuric 

Skatoxyl. — Skatoxyl results from the skatol formed during the 
process of intestinal putrefaction, as indoxyl is derived from indol, 
is partly eliminated in the urine as skatoxyl sulphate. Clini- 
callv it is of little interest, as the amount excreted is very -mall, and 
it is not necessary to enter into a further consideration of its chemi- 
cal properties or mode of detection at this place | , see Feces 



CONJUGATE SULPHA 77.X 483 

Phenol. — Phenol, according to Brieger, occurs only in very small 
amounts in human urine, the usual phenol reactions being largely 
referable to paracresol. Normally, about 0.03 gramme is eliminated 
in the twenty-four hours, but in pathological conditions much larger 
quantities may be found. Remembering the origin of phenol, it is 
char that an increased elimination may be observed whenever putre- 
factive processes arc going on in the tissues and cavities of the body, 
or whenever there is an increase in the degree of intestinal putre- 
faction, though in the latter condition the indican is usually the only 
conjugate sulphate that is found increased. In peritonitis, diph- 
theria, erysipelas, scarlatina, empyema, pulmonary gangrene, putrid 
bronchitis, etc., an increased elimination of phenol is commonly 
seen. Important from a diagnostic standpoint, further, is the fact 
that in uncomplicated cases of typhoid fever no increase is observed, 
while this is common in tubercular meningitis. 1 The largest amounts, 
of course, are seen in cases of poisoning with carbolic acid or one of 
its derivatives. 

As the quantitative estimation of phenol is too complicated for the 
purposes of the general practitiouer, Salkowski's qualitative test is 
here also described. From the intensity of the reaction certain con- 
clusions may be drawn as to the amount present. It is especially 
serviceable in cases of suspected poisoning with carbolic acid. 

Salkowski's Test. — About 10 c.c. of urine are boiled in a test- 
tube with a few cubic centimeters of nitric acid, and, on cooling, 
treated with bromine-water. The development of a pronounced 
turbidity or the occurrence of a precipitate indicates the presence 
of an increased amount of phenol. 

Quantitative Estimation. — J y rincij)/e. — When potassium-phenyl 
sulphate is treated with hydrochloric acid, phenyl sulphate results, 
which further takes up one molecule of water, giving rise to the 
formation of sulphuric acid and phenol, according to the following 
equations : 

/O.C 6 H 5 /O.C 6 H 5 

(1) S0 2 < +HC1= KC1 +SO a < 

N)K X)H 

/O.CJI, /OH 

(2) S0 2 < +H,0 = SO/ < 6 II 5 .OH. 

From the action of bromine-water upon phenol a yellowish-white 
crystalline precipitate of tribromophenol results : 

C 6 H 5 .OH + 6Br = 3HBr + C 6 H 2 BivOH. 

1 A. Strasser, "Ueber d. Phenolausscheidang bei Krankheiten," Zeit. f, klin. Med., 
vol. xxiv. i>. r>4:j. Brieger, Zeit. f. klin. Med., 1881, vol. iii. p. 468. Kast u. Boas, 
Munch, med. Woch., 1888. vol. xxxv. p. 55. 



484 THE URINE 

As 331 molecular weight) parts by weight of tribromophenol 
correspond to 94 (molecular weight) parts by weight of phenol, the 
amount of the latter contained in a certain volume of urine is readily 
determined according to the equation 

331:94:: x:y; and y =~ = 0.28398 x, 

331 

in which x indicates the weight of the trior oinophenol found in the 
amount of urine employed, and y the corresponding quantity of 
phenol. 

Method. — From 500 to 1000 c.c. of urine are treated with one-fifth 
of an equivalent amount of dilute hydrochloric acid (1 : 4), and dis- 
tilled so long as a specimen of the distillate is rendered cloudy upon the 
addition of bromine- water f 1 : 30 ). the specimens used fo this purpose 
being carefully preserved. The total quantity of the filtered dis- 
tillate, together with the specimens which have been set aside, is now 
treated with bromine-water, shaking the mixture after each addition 
of the reagent until a permanent yellow color results. Beyond this 
point further addition is beset with danger, as compounds will be 
formed which contain inore bromine, the presence of which would 
indicate a smaller amount of phenol than that actually contained in 
the urine. Alter two or three days the precipitate is collected on a 
filter which has been dried over sulphuric acid, washed with water 
containing a trace of bromine, and then dried over sulphuric acid 
and weighed. 

Pyrocatectrin. — Urines containing pyroeateehin, like those con- 
taining hydrochinon (see above), darken upon standing, though 
presenting a normal color when voided. 

ACETONE. 

The amount of acetone which may be found in the urine under 
normal conditions varies between 0.008 and 0.027 gramme, and is 
greatly influenced by the character of the diet. Whenever the car- 
bohydrates are withdrawn the quantity rapidly increases, and reaches 
its maximum about the seventh or eighth day. At this time from 
to 700 mgrms. may be eliminated in the twenty-four hours. 
If. then, carbohydrates are again added to the diet, the acetonuria 
soon disappears. This result is not reached, however, if fats are sub- 
stituted for the carbohydrates. The acetonuria is greatest when but 
little albuminous food and no carbohydrates at all are ingested, and 
during starvation the same amounts are essentially found. There 
can hence be no doubt that acetone is derived from proteid material. 
Increased amounts are accordingly found whenever, as in fevers, the 
various cachexias, in conditions associated with inanition, etc., large 



ACETONE. 485 

quantities of circulating albumin are broken down, or whenever car- 
bohydrates are not furnished in sufficient amount. 1 

Most important is the diabetic form of acetonuria, and it may be 
stated, as a general rule, that the diagnosis of diabetes mellitus Is 
justifiable whenever sugar and notable quantities of acetone are 
found in the urine. The amount of acetone, moreover, stands in a 
direct relation to the intensity of the disease, the maximum excretion 
being usually observed toward the fatal end. 2 Whether or not this 
form of acetonuria can always be explained upon the basis given 
above remains an open question. There can be no doubt, however, 
that the threatening symptoms which are so commonly associated 
with a greatly increased elimination of acetone will often disappear 
when carbohydrates are administered in large amounts. It is certain, 
moreover, that diabetic coma is more apt to occur when the old- 
fashioned plan of excluding carbohydrates entirely from the dietary 
of diabetic patients is adopted. Hirschfeld 3 suggests that in every 
case of diabetes the excretion of acetone be carefully followed, and 
that large amounts of carbohydrates be administered whenever the 
acetonuria approaches a dangerous extent. This agrees with my 
experience. 

Of the febrile diseases in which acetonuria has been observed 
may be mentioned typhoid fever, pneumonia, scarlatina, measles, 
acute miliary tuberculosis, acute articular rheumatism, and septi- 
caemia. In those of short duration, on the other hand, even if the 
fever is high, as in acute tonsillitis, intermittent fever, the hectic 
fever of phthisis, etc., an increased elimination of acetone is rarely 
observed. In the continued fevers the acetonuria is largely referable 
to the character of the diet, as carbohydrates are usually excluded 
entirely, and I have repeatedly observed that a return to the normal 
occurred as soon as sugar was administered in amounts varying from 
50 to 100 grammes. 

In certain nervous and mental diseases, as in general paresis, mel- 
ancholia, following epileptic seizures, and in tabes, acetonuria is fre- 
quently observed. During the second stage of general paresis in- 
creased amounts are indeed quite constantly found, but Hirschfeld 
i- probably correct in stating that the psychotic form of acetonuria 
is largely referable to improper feeding. 

In the primary diseases of the stomach, and notably in carcinoma, 
acetonuria i< frequently observed, and it is possible that the acetone 
in these eases is to some extent at least formed in that organ directly 
from the proteids ingested. The fact that in carcinoma acetone may 

1 v. Jaksch, Ueber Acetonuric o. Diaceturie, Hirschwald, Berlin. 1885. Rosenfeld, 
Centralbl. f. inn. Mod., 1895, vol. xv. Waldvogel, "/nr Lehre von der Acetonnrie," 

Zeit. f. klin. Med., vol. xxxviii. p. 506. 

2 v. Jaksch, Zeit. f. klin. Med., 1885, vol. x. ]». 362. Lorenz, [bid., 1891, vol. xix. 

p. 19. 

3 F. Hirschfeld, " Beobachtun.sen iiber d. Acetonuric u. das Coma diabeticum," 
Zeit. f. klin. Med., vol. xxviii. p. 176, and vol. xxxi. p. 212. 



486 THE URINR 

be observed at a time when marked loss of flesh has not as yet 
occurred, and that larger amounts of acetone may be found in the 
stomach than in the urine, is certainly in favor of this view. 1 

The acetonuria following chloroform narcosis is probably refer- 
able to an increased destruction of organized albumin. Finally, the 
possibility of the occurrence of an enterogenic form of acetonuria 
must be borne in mind. The cases of so-called asthma acetonicum 
probably belong to this class. 

Tests for Acetone. — Legal's Test. 2 — This test may be applied 
to the freshly voided urine, but is not conclusive. Several cubic 
centimeters of urine are treated with a few drops of a strong solution 
of sodium nitroprusside and sodium hydrate : the mixture assumes 
a red color, which rapidly disappears; and in the presence of acetone 
is replaced by a purple or violet red when acetic acid is added. As 
a rule, it is safer to distil the urine (500-1000 c.c.) after the addi- 
tion of a little phosphoric acid (1 gramme pro liter), and to employ 
the first 10-30 c.c. of the distillate for the following two tests. 

Lieben's Test. 3 — A few cubic centimeters of the distillate are 
treated with several drops of a dilute solution of iodo-potassic 
iodide and sodium hydrate, when in the presence even of traces of 
acetone a precipitation of iodoform in crystalline form occurs, which 
may be readily recognized by its odor when the solution is heated. 

Reynolds' Test. 4 — A few cubic centimeters of the distillate are 
treated with a small amount of freshly precipitated yellow mercuric 
oxide. This is prepared by precipitating a solution of mercuric 
chloride with an alcoholic solution of sodium hydrate. If acetone 
is present, a black color, due to the formation of mercuric sulphide, 
will result in the clear filtrate upon the addition of a few drops of 
ammonium sulphide. 

Denniges' Test (as modified by OppenheimerV — The reagent is 
prepared as follows : 20 grammes of concentrated sulphuric acid 
are poured into 100 c.c. of distilled water, when 5 grammes of 
freshly prepared yellow mercuric oxide (see Eeynolds' test) are 
added. The mixture is allowed to stand for twenty-four hours and 
is then ready for use. 

This reagent is added to about 3 c.c. of urine, drop by drop, 
until the precipitate which is thus formed no longer disappears on 
stirring. When this point is reached a few more drops are added. 
After two to three minutes the precipitate is filtered off. The clear 
filtrate is further treated with about 2 c.c. of the reageut. and 3-4 
c.c. of a 30 per cent, solution of sulphuric acid, and boiled for a 
minute or two, or. still better, placed in a vessel with boiling water. 

1 H. Lorenz. loc. cit. 

- Le Xobel. Arch. f. exper. Path. u. Pharmakol.. 1S^4. vol. xviii. p. 9. 

3 Taniguti u. 5alknw>ki. Zeir. f. physiol. Chem.. 1690. vol. xiv. p. 476. 

4 Gunning. Jour, de Pharmacol, et deChim.. 1881, vol. iv. p. 30. 

5 Oppenheirner. Berlin, klin. Woch., 1599. p. 828. 



ACETONE. 487 

In the presence of an abundant amount of acetone a copious white 
precipitate forms immediately ; while in the presence of traces only 
(less than 1 : 50000), a slight cloud develops on standing for several 
minutes. The precipitate is almost entirely soluble in an excess of 
hydrochloric acid. 

If albumin is present, the urine becomes turbid at once when the 
reagent is added. In that case the test is continued as described, 
attention being directed to the coarser precipitate which occurs later. 
To such urines large amounts of the reagent must be added, the idea 
being to precipitate everything that can be precipitated with the 
reagent, before heating. 

It will be observed that Denniges' test is much simpler than the 
tests already described, and Oppenheimer claims that it is as delicate 
as that of Lieben, viz., giving a well-pronounced reaction with a 
dilution of 1 : 20000, and being still discernible with a dilution of 
1 : 60000. As diacetic acid yields acetone when treated with 
mineral acids, a positive result is always obtained when this is pres- 
ent. But as diacetic acid is usually found only in association with 
acetone, this fact does not lessen the value of the test, and is an 
error, moreover, which is common to the other tests as well. 

Quantitative Estimation of Acetone. — For the purpose of 
estimating the amount of acetone the method of Messinger, as 
modified by Huppert, is now employed, and is greatly to be preferred 
to the older procedure of v. Jaksch. 1 

Principle. — The method is based upon the observation of Lieben 
that acetone gives rise to the formation of iodoform when treated 
with iodine in an alkaline solution. If, then, a solution of acetone is 
treated with a known amount of iodine, it is a simple matter to 
determine the quantity present by retitrating the iodine which was 
not used in the formation of iodoform. 

Solutions required : 

1. Acetic acid (50 per cent, solution). 

2. Sulphuric acid (12 per cent, solution). 

3. Sodium hydrate solution (50 per cent.). 

4. A decinormal solution of iodine. 

•",. A decinormal solution of sodium thiosulphate. 
6. Starch solution (see page 189). 
Preparation of the solutions: 

1. The decinormal solution of iodine i- prepared as described 
elsewhere (see page 188). 

2. As the molecular weight of sodium thiosulphate — NaJSgOj -f 
5H..O — is 2 18, a decinormal solution of the salt Mould contain 24.8 
grammes to the liter. This quantity is dissolved in about 950 c.c. 
of distilled water, and brought to the proper strength by titration 

1 See Xeubaueru. Vogel, Analyse des Hams. 9th ed., p. 470. 



488 THE URINE. 

with a decinormal solution of iodine. As 1 c.c. of the thiosulphate 
solution should correspond to 1 c.c. of the iodine solution, the neces- 
sary amount of water which must be added to the former is then 
determined. 

Method. — One hundred c.c. of urine, or less if much acetone is 
present, as determined by Legal' s test, are treated with 2 c.c. of the 
acetic acid solution and distilled until seven-eighths of the total 
amount have passed over. The distillate is received in a retort 
which is conuected with a bulb-tube containing water. As soon 
as seven-eighths of the urine have distilled over, a small amount 
of the distillate of the remainder is tested for acetone according 
to Lieben's method. Should a positive reaction be obtained, it 
will be Decessary either to repeat the entire process with less urine, 
diluted to about 200 c.c, or to add about 100 c.c. of water to the 
residue and to distil until all the acetone has passed over. The 
distillate is then treated with 1 c.c. of the sulphuric acid and redis- 
tilled. The addition of the acetic acid and of the sulphuric acid, 
respectively, serves the purpose of holding back phenol and am- 
monia. Should the first distillate contain nitrous acid, moreover, 
which is recognized on the addition of a little starch paste contain- 
ing a trace of potassium iodide, when the solution turns blue, the 
acid is removed by adding a little urea. The second distillate is re- 
ceived in a bottle provided with a well-ground glass stopper, and 
holding about 1 liter. The distillate is then treated with a carefully 
measured quantity of the one-tenth normal solution of iodine, — 
about 10 c.c. for 100 c.c. of urine, — and sodium hydrate solution 
until the iodoform separates out. To this end, a slight excess of the 
solution must be added. Should ammonia be present, a blackish 
cloud will be observed at the zone of contact of the sodium hydrate 
and the iodine solution, and it will be necessary to repeat the entire 
process. The bottle is closed and shaken for about one minute. 
The solution is then acidified with concentrated hydrochloric acid, 
when the mixture assumes a brown color if iodine is present in 
excess. If this does not occur, more of the iodine solution must 
be added, and the process repeated until an excess is present. The 
excess is then retitrated with the thiosulphate solution until the fluid 
presents a faint-yellow color. A few cubic centimeters of starch 
solution are now added, and the titration continued until the last 
trace of blue has disappeared. The number of cubic centimeters 
employed in the titration is finally deducted from the total amount 
of the iodine solution added, and the result multiplied by 0.976. 
The figure thus obtained indicates the amount of acetone contained 
in the 100 c.c. of urine, in mgrms., as 1 c.c. of the thiosulphate 
solution is equivalent to 1 c.c. of the iodine solution, or to 0.967 
mgrm. of acetone. 



DIACETIC ACID. 489 

DIACETIC ACID. 

The occurrence of diacetic acid in urine must always be regarded 
as abnormal. Its pathological significance is identical with that 
of acetonuria. It is met with especially in diabetes, in various 
digestive diseases, and in febrile diseases. In the continued fevers 
of childhood it is almost constantly present. 

In order to demonstrate the presence of diacetic acid a few cubic 
centimeters of urine are treated with a strong solution of ferric 
chloride added drop by drop. Should a precipitation of phosphates 
occur, these are filtered off, when more of the iron solution is added 
to the filtrate. If now a Bordeaux-red color appears, another por- 
tion of the urine is boiled and similarly treated. If in the second 
tot no reaction is obtained, a third portion of the urine is treated 
with sulphuric acid and extracted with ether. A positive reaction, 
when the ethereal extract is tested with ferric chloride, the color dis- 
appearing upon standing for twenty-four to forty-eight hours, will 
indicate the presence of diacetic acid, particularly if the urine is rich 
in acetone. 

Arnold's Test. — Two solutions are employed, viz., a solution 
of para-amido-aeeto-phenon and a 1 per cent, solution of sodium 
nitrite. The first is prepared by dissolving 1 gramme of para- 
amido-aeeto-phenon in from 80 to 100 c.c. of distilled water, and 
adding hydrochloric acid drop by drop until the solution, which at 
first is yellow, becomes colorless ; an excess, however, should be 
avoided. Immediately before using, the two solutions are mixed in 
the proportion of two to one. A few r cubic centimeters of the reagent 
are then treated with an equal volume of urine, and a few drops of 
ammonia added. Thus treated, all urines give a more or less marked 
brownish-red color on shaking ; and if much diacetic acid is present, 
an amorphous reddish-brown sediment is thrown down. A small 
amount of the colored solution is then placed in a conical glass and 
treated with an excess of concentrated hydrochloric acid (10-12 c.c. 
for each 1 c.c). In the presence of diacetic acid the mixture assumes 
a beautiful purplish-violet color. 

According to Arnold, the test is more delicate than that of Ger- 
hardt, and does not respond with acetone or oxybutyric acid. With 
bilirubin and the common antipyretics, as well as salicylic acid, no 
reaction is obtained. Highly colored urines should first be filtered 
through animal charcoal. 

According to Lipliawski, the following modification of Arnold's 
test is even more sensitive : two solutions are employed, viz., a 1 per 
cent, solution of para-amido-aeeto-phenon and a 1 percent, solution 
of potassium nitrate. Six c.c. of the first solution and 3 c.c. of the 
second are added to an equal volume of urine, to which a drop of 
ammonia has been added. The mixture is shaken until it assumes 



490 THE URISE. 

a brick-red color, when a small amount 10 drops to 2 e.c. is added 

to a solution of 15—20 c.c. of e ncentrz ted hydrochloric acid, 3 c.c. 

bloroform, and 2—4 drops of an aque us - lata n of ferric chloride. 

After gently shaking this mixture, care being taken not to emulsify 

the chloroform, a beautiful and very characteristic violet tinge results 
if diacetic acid is present. 

Liteeattee. — v. Jaksch. Leber Acetonurie u. Diaceruxie, loc. cit. Idem.. Zeit. f. 
Heilk.. 1882, vol. iii. p. 34. Schrack. Jahrbuch f. Kinderheilk., 1839, vol. xxix. p. 411. 
V. Arnold. Wien. klin. Woeh., 1899, p. 541. 

OXYBUTYRIC ACID. 

The fact that in some cases of diabetes an excessive elimination of 
ammonia was - ~ *d le I to the belief that there must be present an 
unknown acid : this was shown I ; -oxybutyric acid. The occur- 

rence of this acid in the urine of diabetic patients is of great clini- 
cal interest, as a possible connection has been established betwc 
its presence in the blood and diabetic coma. The latter condition is 
explained by assuming that the diabetic patient is unable to furnish 
sufficient ammonia to neutralize the acid- I in the tissues : 

the body, the alkalies oi' the blood being consequently attacked. A 
prophylactic treatment with alkalies, such as intravenous injections, 
has hence been suggested in severe :.;->. This, however, is a mere 
theory, and the fact that a case of diabetic coma has been reported 
in which the alkalinity of the blood was not diminished, and in 
which recovery took place without the use of alkalies, renders the 
correctness of the hypothesis doubtful Possibly the cause of the 
coma is due to the presence ■:<! toxins circulating in the blood, which 
produce an increased tissue-destruction, with a sbnultane us forma- 
tion of oxybutyric acid, from which diacetic acid and acetone may 
further result. However this may be. the presence of oxybutyric 
acid may always be regarded as indicating a severe type of the dis- 

- . nd, when associated with marked acetonnria and diaceturia. as 
indicating dangei : soma. 

The presence of oxybutyric acid may be inferred in diabetic 
urines if after fermentation a rotation of the plane of polarized 
light to the left is observed. 

Liteeattee. — v. Jaksch. Ueber Acetonurie u. Diaceturie. loc. cit. H. Wolpe, 
Arch. f. exper. Path. u. Pharmakol.. 1SS6, vol. xxi. p. 131. 

LACTIC ACID. 

Sarcolactic acid is normally absent from the urine, but is met with 
in pathological conditions, and particularly in hepatic diseases, as 
the liver is normally concerned in the decomposition of lactic acid and 
of the lactates that have be gested with the food. As has 

been pointed out, moreover, there is evidence to -how that by far 



VOLATILE FATTY ACIDS. 41)1 

the greatest portion of the nitrogen eliminated from the body reaches 
the liver as ammonium lactate, and is here synthetically transformed 
into urea. As a consequence, lactic acid appears in the urine when- 
ever, as in phosphorus poisoning, acute yellow atrophy , etc., an 
extensive destruction of the hepatic parenchyma occurs, and the 
formation of urea is consequently impaired. In such cases the 
elimination of lactic acid is associated with an increased excretion 
of ammonia. The same will occur when, owing: to insufficient oxv- 
genation of the blood, the power of oxidation on the part of the 
liver is interfered with. We accordingly find lactic acid in the urine 
in the chronic anaemias, in cases of poisoning with carbon monoxide, 
in association with the various forms of circulatory and respiratory 
dyspnoea, in cases of epilepsy immediately after the attack, following 
excessive muscular exercise, as in soldiers after forced marches, etc. 
In order to test for lactic acid, the urine is evaporated on a water- 
bath to a thick syrup and extracted with 95 per cent, alcohol. This 
is decanted off' after twenty-four hours, evaporated to a syrup, acidi- 
fied with dilute sulphuric acid, and extracted with ether so long as 
this presents an acid reaction. The ether is then distilled off' and 
the residue dissolved in water. This solution is treated with a few 
drops of a solution of basic lead acetate, filtered, the excess of lead 
removed by means of hydrogen sulphide, and the filtrate evaporated 
to dryness on a water-bath, when the lactic acid will remain behind 
as a slightly yellowish syrup. This is then dissolved in a little 
water, the solution is saturated with zinc carbonate, and boiled. 
Zinc lactate will separate out upon evaporation, especially if a little 
alcohol is added, and may be recognized by the form of its crystals, 
viz., small prisms. These crystals are lsevorotatory, soluble jn alco- 
hol (1 : 1100), and contain two molecules of water of crystallization, 
which is lost at 105° C, so that the loss of weight after heating to 
this temperature must correspond to 12.9 per cent. 

Literature. — O. Minkowski. "Ueber don Einflnss d. Leberextirpation auf d. 
Stoffwechsel," Arch. f. exper. Path. u. Pharmakol., vol. xxi. p. 41 ; and " Ueber d.Ur- 
Bacbe d. Milchsaureausscheidung nach Leberextirpation," [bid., vol. xxxi. p. 214. 
G. Colosanti n. K. Moscatelli, "Ueber d. Milchsauregehalt d. menschlichen Hams, 
Ibid., vol. xxvii. p. 158. 

VOLATILE FATTY ACIDS. 

The term lipaeiduria has been applied to an increased elimina- 
tion of volatile fatty acids in the urine, and may be observed in 
various hepatic diseases affecting the glandular structure of the liver, 
in leukaemia, in diabetes, in purulent peritonitis, phlegmonous ton- 
sillitis, erysipelas, etc. Traces of fatty acids an- also found under 
normal conditions, and are probably formed in the lower segment 
of the small intestine. The fatty acids which have thus far been 
isolated from the urine are formic, acetic, butyric, and propionic 
acid. Thev mav be demonstrated in the same manner as described 



492 THE URINE. 

in the chapter on Feces. According to some observers, the amount 
of fatty acids in the urine may be regarded as an index of the 
degree of carbohydrate fermentation in the intestinal tract. Under 
normal conditions this may be the case, but in disease the ques- 
tion is probably more complicated. 

Liteeatube. — v. Jaksch, Zeit. f. klin. Med., 1886, vol. xi. p. 307 ; and Zeit. f. 
physiol. Chem., 1886, vol. x. p. 536. 

FAT. 

Under strictly normal conditions the urine contains no fat, while 
variable amounts may be found in disease. When present in large 
quantities, so that it is possible to recognize it with the naked eye, 
the condition is termed lipuria. Such cases, however, are rare, and 
the diagnosis should only be made when it is possible to exclude an 
accidental contamination of the urine. Smaller quantities of fat, 
recognizable only with the microscope, are much more common, and 
are indeed quite constantly observed whenever fatty degeneration of 
the renal epithelial cells, of pus-corpuscles, or of tumor-particles is 
taking place in the urinary tract. The fat-droplets may then be found 
floating in the urine or attached to or imbedded in any morphological 
elements that may be present. Lipuria may also occur when ab- 
normally large quantities of fat are circulating in the blood. It is 
thus observed after the administration of cod-liver oil in large quan- 
tities, following oil inunctions, in cases of fracture of the long bones 
with extensive destruction of the bone-marrow, in cases of eclampsia, 
as also in such diseases as diabetes mellitus, chronic alcoholism, 
phthisis, obesity, leukaemia, in certain mental diseases, in affections 
of the pancreas and heart, etc. 

The term chyluria or galacturia has been applied to a condition 
in which a turbid urine presenting the macroscopical appearance of 
milk is excreted. Upon microscopical examination it may be de- 
monstrated that the turbidity in such cases is owing to the presence 
of innumerable highly refractive globules of fat, which may be 
removed by shaking with ether. Of morphological constituents, 
leucocytes are occasionally encountered in large numbers. Red 
blood-corpuscles are also seen at times, and when present in large 
numbers impart a rose color to the urine. Fibrinous coagula are 
often observed when the urine has stood for some time, and the 
entire bulk of urine may even become transformed into a gelatinous 
mass. Albumin is present in most cases in the absence of other 
constituents pointing to renal disease, such as tube-casts and renal 
epithelial cells. Leucin, tyrosin, and cholesterin may also at times 
be found, particularly the latter. Formerly it was quite gen- 
erally accepted that this condition was due to the presence of the 
Filaria sanguinis hominis ; but while filarise are undoubtedly pres- 



FERMENTS— OASES. 493 

ent in the blood in the majority of instances, and may also be pres- 
ent in the urine, it has boon demonstrated that oases occur in which 
tilariasis docs not exist, and Gotze expressed the opinion that ehv- 
luria may he owing to a distinct anatomical lesion affecting the renal 
parenchyma. Further observations, however, are necessary in order 
to clear up not only the etiology of the disease, but also the manner 
in which the fat and albumin enter the urine. 

Li i kkatikk. — Lipuria : Schiitz, Prag. med. Woch., 1882, vol. vii. p. 322. Ebstein, 
Arch. f. klin. Med., 1879, p. 11.",. Chyluria: Huber, Virchow's Archiv, 1886, vol. 
cvi. p. 126. Rossbach-Gotze, Verhandl. d. Congr. f. iun. Med., 1887, vol. vi. p. 212. 
Brieger, Zeit f. physiol. Chem., 1880, vol. iv. p. 407. Grim, Langenbeck's Archiv, 
1885, vol. xxxii. p. 511. 

FERMENTS. 

Ferments may be demonstrated in every urine, both under physio- 
logical and pathological conditions, but are of little clinical impor- 
tance, excepting, perhaps, pepsin, which is said to be absent incases 
of typhoid fever, carcinoma of the stomach, and possibly also in 
nephritis. In order to demonstrate its presence, a small flake of 
fibrin is placed in the urine, and after several hours removed to a 2 
to 3 pro mille solution of hydrochloric acid. The pepsin, if present, 
will be deposited upon the fibrin, and effect the digestion of the 
latter in the hydrochloric acid solution. Diastase, a milk-curdling 
ferment, and a ferment causing decomposition of urea into carbon 
dioxide and ammonia, have also been observed. 

GASES. 

Every urine contains a small amount of gases, notably carbon 
dioxide, oxygen, and nitrogen, which may be withdrawn by means 
of an air-pump. 

Under pathological conditions hydrogen sulphide is at times also 
found, constituting the condition known as hydrothionuria. In 
some instances this is referable to a diffusion of the gas into the 
bladder from neighboring organs or accumulations of pus ; but this 
is rare. In others an abscess has ruptured into the bladder, or a direct 
communication exists between it and the bowel. Under such con- 
ditions it can, of course, not be surprising that hydrogen sulphide 
together with other products of albuminous putrefaction are elimi- 
nated in the urine. More commonly, however, the hydrothionuria 
occurs idiopathically, and is then referable to the action of certain 
micro-organisms. This can be readily demonstrated by adding a 
few cubic centimeters of such urine to normal urine, when upon 
standing the formation of hydrogen sulphide may be demonstrated 
in the normal specimen. The common organisms, however, which 
cause ammoniacal decomposition apparently have no part in this 
process, and the formation of the hydrogen sulphide may be ob- 



494 THE URINE. 

served before ammoniaeal decomposition has set in and while the 
reaction is yet acid. If a small amount of ordinary decomposing 
mine, moreover, is added to fresh normal urine, no hydrogen sul- 
phide is as a rule produced. The character of the organisms in 
question is variable ; sometimes micrococci are found, at other times 
bacilli, and in still other instances both. Besides being capable of 
producing hydrogen sulphide from the sulphur bodies of the urine, 
some of them also cause the formation of ammonium carbonate in 
dilute solutions of urea. 

The source of the hvdrogen sulphide in cases of hydrothionuria 
is in most cases probably the so-called neutral sulphur, but it is pos- 
sible that the oxidized sulphur is at times also attacked. Very in- 
teresting is the fact that in cystinuria, in which the neutral sulphur 
is more or less increased, hydrothionuria is commonly observed. 
Its occurrence in such cases is indeed so frequent that I am in- 
clined to suspect cystinuria. although crystals of cystin are not 
found in the sediment. Further work in this direction, however, 
is needed, and especially to determine the relative frequency with 
which the two conditions are associate:!. 

In a few recorded instances the hydrothionuria accompanied 
indigosuria. viz.. the presence of free indigo-blue in the urine ; and 
this Muller has likewise shown to be referable to the action of cer- 
tain microorganisms. One case of this kind I saw several years 
ago. but made no examination for the presence of cystin. 

Owing to the well-known poisonous effect of hydrogen sulphide 
upon the blood, it is well in every case to ascertain whether its 
formation occurs in the bladder, or whether it takes place only on 
standing. The formation of hydrogen sulphide in decomposing urines 
containing albumin is. of course, common, and should not be con- 
fused with the idiopathic hydrothionuria here described. 

The chemical test for hydrogen sulphide is very simple : a strip 
of filter-paper ls moistened with a few drops of sodium hydrate 
and lead acetate solution and clamped into the neck of the bottle 
containing the urine. After a variable length of time, in some 
instances immediately, in others only after twelve to twenty-four 
hours, a discoloration of the paper will be observed, varying from 
a grayish brown to black according to the amount present. When 
this is large it is, of course, also recognized by its characteristic odor. 

Liteeattee. — F. Muller. " SchwefelwasserstotF im Harn.'* Berlin, klin. Woch.. 
1887, Nob. '23 and -24. Rosenheim u. Gutzmann. Deutsch. med. Woch.. 1888, Xo. 10. 
Kahler, Prag. med. Woch.. 1888, >o. 50. 

PTOMAINS. 

Numerous researches have shown that traces of toxic alkaloidal 
substances may be encountered in the urine under the most diverse 
pathological conditions, and may be present even in health. Of 



PTO MAINS. 495 

the nature of these bodies, however, little is known. Thudichum 
claims to have isolated three distinct basic substances from normal 
urine, which he has termed reduein, parareducin, and arcmin, 
Pouchet and Mine. Eliacbeff, working in Gander's laboratory, have 
likewise extracted toxic bodies from normal urines; and Adduco 
states that alter fatiguing exercise, especially, he could demonstrate 
in the urine a substance which was extremely toxic, and was not iden- 
tical with cholin, as was first supposed. All this work, however, must 
be repeated with great care before the results obtained can be 
regarded as conclusive. This is also true of the work which has 
been done in various diseases. Some observers have here described 
bodies which they regard as specific toxins. Griffith thus reports 
the presence of a specific poison of scarlatina, of measles, mumps, 
etc. Others again have obtained only negative results. 

The only substances belonging to the class of ptomai'ns which have 
thus far been obtained from the urine in amounts sufficient to estab- 
lish their identity are cadaverin and putrescin. They were originally 
discovered by Brieger in putrefying cadavers, and subsequently also 
found in cultures of the bacillus of Asiatic cholera, the Finkler- 
Prior bacillus of cholerina, the bacillus of tetanus, and in the rice- 
water stools of cholera patients. From the urine cadaverin, putrescin, 
and a third diamin isomeric with cadaverin, and which has been 
regarded as saprin or nenridin, were first obtained by Baumann and 
v. Udranszky in a ease of cystinuria, and it appears that dia- 
minuria occurs only in association with this disease. All attempts 
to isolate diamins from the urine under other pathological conditions 
at least have given rise to negative results. Whether or not diamin- 
uria is invariably associated with cystinuria is, however, an open 
question. Putrescin has thus far been found in only three cases, 
viz., in the first case of Baumann and v. Udranszky, in Bodtker's 
case, and in a recent, as yet unpublished, case by Garrod. Brieger, 
Stadthagen, Leo, Garrod, Lewis, and I have succeeded in isolating 
cadaverin from such urines. Others have been less successful, and 
the theory which was announced shortly after Baumann's discovery, 
and quite generally accepted, namely, that the formation of the 
diamins in question is in some manner responsible for the appear- 
ance of eystin in the urine, was certainly premature. This is even 
more true of the inference drawn from this supposed association, 
viz., that cystinuria is a specific infectious disease of the intestinal 
canal. This conclusion was based upon the belief that diamins are 
formed from albuminous material only in the presence <>f* certain 
bacteria. I have shown, however, that this is not necessarily the 
case, and that putrescin at least may be formed in the absence 
of micro-organisms. Further investigation will show whether 
or not cystinuria is invariably accompanied by diaminuria. Per- 
sonally I incline to the belief that this is the ease ; but I have 



496 THE UEISE. 

also shown that while cystinuria and diaminnria may coexist, this 
is not always so, and that the two conditions may alternate, and 

that the one may temporarily disappear while the other continues. 
Like Moreigne, I have been led to the conclusion that diaminnria is 
a metabolic anomaly analogous to diabetes and gout, and that both 
diaminnria and cystinuria are the expression of a marked impairment 
of the normal oxidation-prc ess - of the body. 

The amount of diamins which may be met with in the urine of 
cystinuric patients is extremely variable. In one case I was able 
to isolate as much a- 1.6 grammes of the benzovlated cadaverin from 
the collected urine of twenty-four hours. 1 On other days traces 
only were present, and at times, as I have already stated, no diamins 
at all could be found. A few observers who have investigated this 

nestion, state that they were unable to find even traces of diamins 
in their ea-es : but as single examinati as nly were made, their 
conclusion that diaDiinuria does not always accompany cystinuria is 
scarcely justifiable. When single negative results are obtained, the 
examination should be repeated at frequent intervals or larger quan- 
tities of urine employed. In general. I should advise those who 
wish to investigate the question of ptomalnuria to experiment with 
large quantities of urine only, as some of the bodies belonging to 
this order exhibit a degree of toxicity which is out of all proportion 
to the amount present. Where specific alkaloids are t<:> be souo-ht 
for, it is scarcely worth while to use le-s than 100 or 200 liters of 
uriDe. and evt-n with such amounts the results are frequently disap- 
pointing. In cases of cystinuria much smaller quantities will 
usually suffice, and an initial experiment may be made with the 
collected urine of twenty-four hours. 

Isolation of Diamins. — Method of Baumann and v. Udranszky. — 
The collected urine of at least twenty-four hours is shaken with a 
10 per cent, solution of sodium hydrate and beDzoyl chloride in the 
proportion of 1500 : 200 : 25 until the odor of the benzoyl chloride 
has entirely disappeared The resulting precipitate contains phos- 
phates, the benzoyl compounds of the normal carbohydrates of the 
urine, and a portion of the benzoylated diamins. These are filtered 

- with the aid of a suction-pump and digested with alcohol. The 
filtered alcoholic extract is concentrated to a small volume and 
poured into about 30 times its amount of water. Upon standing for 
from twelve to forty-eight hours the benzoylated diamins separate out 
in the milky fluid in the form of a more or less voluminous sediment 
composed of fine, intensely white crystals. In order to remove 
the benzoylated carbohydrates likewise present, the precipitate is 
redissolved in alcohol, the solution concentrated to a small volume. 
and diluted with water as described. This process is repeated several 

1 Id the ea- which was examined in my laboratorv. 0.3 gramme only 

could be obtained from 12.000 c.c. 



PTOMAINS. 497 

times. The resulting crystals, if both diamins are present, will lose 
their water of crystallization at 120° C. and mell at 1 40° C. 

A smaller portion of the benzoyl diamins remains in the first fil- 
trate. In order to recover this, the filtrate is acidified with sulphuric 

acid and extracted with ether. The ethereal residue, before congeal- 
ing, is placed in as much of a L2 per cent, solution of sodium 
hydrate as is required for its neutralization, when from 3 to 4 times 
the volume of the same solution is added. This mixture is placed 
in the cold, when long needles and platelets separate out, which 
consist of the sodium compound of benzoyl cystin and the benzov- 
lated diamins. The sediment is filtered off and placed in cold water, 
in which the sodinm-benzovl cystin dissolves, while the benzovlated 
diamins remain undissolved. 

In order to separate the putrescin from the cadaverin, the crystals 
are dissolved in a little warm alcohol and treated with 20 times the 
volume of ether. Benzoyl-putrescin is thus thrown down, and may 
be recognized by its melting-point, viz., 175°-176° C, while the 
ethereal residue contains the benzovl-cadaverin, which melts at from 
129° to 130° C. 

The diamins may then be separated from the benzoyl radicle by 
heating the crystals on a water-bath with a mixture of equal parts 
of alcohol and concentrated hydrochloric acid until a specimen is 
entirely dissolved by sodium hydrate. The separation is complete 
after from twenty-four to forty-eight hours, according to the amount 
present. The solution is then diluted with water, when the benzoic 
acid, which has been formed, separates out and is filtered off. After 
extracting with ether, in order to remove any benzoic acid still 
remaining, the nitrate is evaporated to dryness. A crystalline mass 
remains, which is easily soluble in water but with difficulty in 
alcohol. This consists of putrescin and cadaverin hydrochlorates, 
from which the various double salts with platinum, silver, mercury, 
etc., can be readily obtained. The platinum salt of cadaverin is 
formed by adding an alcoholic solution of platinum chloride to a 
solution of the hydrochlorate in alcohol ; it occurs as a voluminous 
yellow crystalline mass, which can be purified by recrystallization 
from hot water. When this salt is decomposed by hydrogen sulphide 
the hydrochlorate again results, from which the free base is obtained 
by distillation with caustic potash. During this distillation water 
passes over at first; and above 160° C. a colorless oil appears, the 
boiling-point of which is about 173° C. This constitutes the \'wc 
base> which may be identified by its sperm-like odor and the avidity 
with which it attracts carbon dioxide from the air to form a carbo- 
nate. 

Literature.— Stadthagen. "Ueberd. Harngift," Zoit. f. klin. Med., 1889, vol. xv. 
p. 383. Bouchard, Compt. rend. Soc. de Biol., 1884; and Compt. rend, de I'Acad. des 
Sci., vol. cii. i>. 1127. Lepine et Aubert, Ibid., vol. ci. p. 90. Adduco, Arch. ital. 
d. Biol., vol. ix. ]>. 203, and x. p. 1. 

22 



493 THE UMINK 

Pmrmnnria, : v. Udranszkv u. Baumann. Zeit. f. physiol. Chem., 1869, vol. xiii. p. 
562. Stadtnagen u. Brieger. Berlin, klin. Woch.. 1SS9. vol. xxvi. p. 344. Bodtker. 
Nozsk. Mag. f. Laegevidensk.. 1592. vol. vii. p. 1:220. iloreigne. Arch.de Med. esper. 
et d'Anat.~path.. Ia99, p. 254. Simon. Am. Jour. Med. Sci., 1900. vol. cxis. p. 39. 
Garrod and Cammidge, Joax. Path, and Bact.. Feb.. 1900. 

MICROSCOPICAL EXAMINATION OF THE URINE. 

Sediments. 

In the chapter treating of the general physical characteristics of 
the urine it was stated that, on standing, every urine gradually be- 
comes cloudy owing to development of the so-called nubecula. This 
was shown to consist of a few mucous corpuscles, a small number 
of pavement epithelial cells derived from the urinary and genital 
passages, and under certain conditions of a few crystals of uric acid, 
of calcium oxalate, or of both. It was further pointed out that 
owing to a diminution in the acidity of the urine on standing, in 
consequence of an interaction between the neutral sodium urate and 
the acid sodium phosphate, a sediment is thrown down which con- 
sists of acid sodium urate, and at times of free uric acid (see Reac- 
tion). Should the reaction of the urine be alkaline, however, when 
freshly voided, a condition which may occur physiologically, when 
it is dependent upon the ingestion of large quantities of vegetables 
rich in organic salts of the alkalies, but which may also be due to 
ammoniaeal decomposition, those constituents of the urine which are 
held in solution merely in consequence of the presence of acid sodium 
phosphate are also thrown down. In that case the sediment consists 
essentially of calcium, magnesium, and ammonium salts. Crystals of 
ammonio-magnesium phosphate, it is true, may also be observed in 
alkaline urines of the first variety, but they are then almost always 
due to an increased elimination of ammonia, and hence are rarely 
observed under physiological conditions. 

formally calcium is found only in combination with phosphoric 
acid and carbonic acid. Of the three possible calcium salts of phos- 
phoric acid—/. cl 3 Ca 3 (P0 4 u CaHP(\, and Ca( ELPO,) — only the 
first two are found in an alkaline urine, but they mav also be observed 
in specimens which are either neutral or but faintly acid. The acid 
calcium phosphate. Ga H_P0 4 )o, is seen but rarely in sediments, and 
its ■: eeurrenee always presupposes the existence of a high degree of 
acidity ; it is precipitated together with uric acid and under similar 
conditions. Calcium carbonate, CaCO,, is seen only in neutral or 
alkaline urines. As soon as ammoniaeal fermentation has begun, 
ammonium salts are, of course, formed, viz.. ammonium urate and 
ammonio-mao;ne-ium phosphate. 

The following table shows the various mineral constituents usually 

- rved in sediments, the reaction of the urine beino; in everv case 
the all-important factor : 



MICROSCOPICAL EXAMINATION OF THE URINE. 199 

Ri action acid: 

Uric acid. 

Sodium urate. 

( lalciiim oxalate. 

Primary calcium phosphate. 

Ammonio-magnesium phosphate. 
Reaction alkaline (referable to fixed alkalies): 

Secondary calcium phosphate. 

Triealcium phosphate. 

Calcium carbonate. 

Ammonio-magnesium phosphate. 
Reaction alkaline (referable to ammonia) : 

Ammonium urate. 

Ammonio-magnesium phosphate. 

Triealcium phosphate. 

Calcium carbonate. 
In pathological conditions still other unorganized substances may 
be observed, viz., cystin, xanthin, hippuric acid, indigo, urorubin, 
bilirubin, haematoidin, magnesium phosphate, calcium sulphate, 
cholesterin, leucin, ty rosin, fats, soaps of magnesium and calcium, 
etc. Of these, cystin, xanthin, hippuric acid, tyrosin, calcium sul- 
phate, bilirubin, hamiatoidin, magnesium phosphate, leucin, and the 
soaps of magnesium and calcium occur principally in acid urines, 
while indigo, urorubin, and cholesterin are usually only found in 
alkaline specimens. Before considering these various constituents 
in detail, a few words regarding sediments in general and the 
method to be followed in their microscopical examination may not 
be out of place. 

An idea of the nature of a deposit may often be formed by simple 
inspection, especially if the reaction of the urine is known. 

A crystalline sediment, presenting a brick-red color and appear- 
ing to the naked eye like cayenne pepper, is usually referable to uric 
acid. On the other hand, a deep-red amorphous deposit occurring 
in an acid urine consists essentially of urates, the color in this case, 
as in the former, being due to uroerythrin. Further proof is hardly 
required. Should doubt be felt, however, it will only be necessary 
to heat the urine, when the deposit will dissolve. A white floccu- 
lent sediment in an alkaline urine is usually referable to a mixture 
of phosphates and carbonates, and will dissolve without difficulty 
upon the addition of acetic acid, but remains unaffected by heat. 

A sediment consisting of pus, and occurring in alkaline urines, is 
frequently mistaken for a phosphatic deposit by the beginner. Aside 
from a microscopical examination, this question may be settled by 
the addition of a small piece of caustic soda and stirring, when in 
the presence of pus the liquid becomes mucilaginous and ropy. If 
much pus is present, a tough, jelly-like mass will be formed, which 



500 THE URINE. 

escapes from the vessel en masse when the urine is poured out. 
Such a sediment, moreover, does not disappear upon the addition 
of an acid, and is rendered still more dense upon the application of 
heat. 

Blood when present beyond traces may also be recognized. 

As a general rule, the non-organized elements of a sediment are 
of little clinical interest. 

Students are frequently in the habit of diagnosing an excessive, 
normal, or subnormal elimination of one or another urinary con- 
stituent from the result of a microscopical examination. This is 
unwarrantable, and it should always be remembered that no con- 
clusions whatsoever can be drawn in this manner as to the 
amount actually eliminated. Nothing would be more erroneous 
than to infer an excessive excretion, not to speak of an exces- 
sive production, of uric acid or of oxalic acid from the fact that 
crystals of these substances are seen in large numbers under the 
microscope. Again and again cases are observed in which an ex- 
cessive elimination of uric acid, oxalic acid, or phosphates is diag- 
nosed by mere inspection, and in which a careful chemical analysis 
shows not only no increase, but even a diminution of the normal 
quantity. 

A urine which is turbid when passed may be examined micro- 
scopically at once. As a rule, however, it is necessary to wait until 
a sediment has formed. To this end, the urine should be kept in 
a clean and well-stoppered bottle. A small amount of chloroform 
is added if necessary, and will preserve the specimen almost in- 
definitely. A few drops of the sediment are then removed by 
means of a dean pipette, carried down to the sediment, with the 
distal end tightly closed by the finger, care being taken not 
to allow the urine to rush into the tube by suddenly releasing 
the pressure, but withdrawing an amount just sufficient for an 
examination. This is then spread over a clean slide that has 
been moistened by the breath, when the specimen may be exam- 
ined at once. Covering the specimen with a slip is not only unnec- 
essary, but even undesirable. A low power of the microscope should 
always be employed, and the high power only used to study details 
of structure. 

If a centrifugal machine is available, it is, of course, not necessary 
to let the urine stand until a sediment has formed. An amount 
sufficient for a microscopical examination can then be obtained in a 
few minutes. 

Non-organized Sediments. 

Sediments occurring in Acid Urines. — Uric Acid. — The form 
which uric acid crystals may present in a deposit varies greatly, the 
most common being the so-called whetstone-form shown in Fig. 94. 



MICROSCOPICAL EXAMINATION OF 'CUE URINE. 501 

The crystals may occur singly or arranged in groups. Accidental 
impurities, such as threads or hairs, arc at times covered with such 
crystals, forming long cylinders. Very frequently uric acid crystal- 
lizes in the form of large rosettes composed of drawn-out whetstone- 
crystals, presenting a deep-red color, referable to uroerythrin, when 
they are often visible to the naked eye, and form the well-known 
brick-dust sediment. "While it is generally stated that uric acid 
crystals can always be recognized by their color, which may vary 
from a light yellow to a dark brown, this is, in my experience, not 
the ease. I have often seen uric acid sediments in which the 
crystals formed small rhombic plates with rounded edges, and 
were absolutely devoid of coloring-matter, so far as a microscopical 
examination could show (Fig. 104). Uric acid "dumb-bells" are 
also at times observed, and may be mistaken for calcium oxalate. 

Fig. 104. 




Colorless crystals of uric acid. 

Hexagonal plates of uric acid have been similarly confounded with 
eystin. 

A uric acid sediment may be observed in cases in which an in- 
creased excretion of uric acid occurs ; but it should be remembered 
that, as a rule, it is not permissible to infer an increased production 
or elimination from the presence of an abundant deposit of this sub- 
stance alone. Brick-dust sediments are frequently observed during 
cold weather; but it would be erroneous to infer an increased elimi- 
nation from such an occurrence, as the phenomenon is owing to 
the fact that uric acid is less soluble in cold than in warm water. 
During the summer month-, for the same reason, a deposit of uric 
acid is less frequently observed, although an increased amount may 
nevertheless be present, being held in solution owing to the higher 
temperature. The more concentrated the urine and the more uric 
acid it contains, the more readily will such a deposit form. It is 
hence noted after profuse perspiration, following severe muscular 
exercise, in acute rheumatism with copious diaphoresis, in acute 



502 THE URINE. 

gastritis and enteritis associated with copious vomiting or diarrhoea, 
during the crisis of pneumonia (particularly if accompanied by 
much sweating), etc. In all these conditions, however, an increased 
elimination of uric acid does not necessarily take place, the all- 
important factors being the reaction of the urine, its degree of con- 
centration, and the surrounding temperature. 

Should formed concretions of uric acid — i. e., uric acid gravel — 
be found in the urine, a direct indication is afforded to diminish the 
acidity of the urine and to increase the amount of water, so as to 
guard against the formation of renal or vesical calculus. 

Chemically, the nature of a uric acid sediment may be recognized 
by the fact that the crystals dissolve upon the addition of sodium 
hydrate, and reappear in the rhombic form upon acidifying with 
hydrochloric acid. When heated with dilute nitric acid the beauti- 
ful red color of ammonium purpurate is obtained upon the subsequent 
addition of ammonia (murexid test), as described elsewhere (see page 
377). 

Amorphous Urates. — Sodium and potassium urate frequently, and 
especially in fevers, form sediments of such density that upon 
microscopical examination it is almost impossible to discern anything 
but innumerable amorphous granules scattered over the entire field 
and obscuring all other elements that may be present. Cells or 
casts will frequently be seen studded with these granules. In such 
cases it is best to heat the urine to a temperature of 50° C, and to 
filter it as rapidly as possible while hot, the contents of the filter 
beiug subsequently used for a microscopical examination. 

Urate sediments are always colored, the tint varying from a dirty 
brown to a bright salmon-red, owing to the presence of uroerythrin. 
Difficulties can hence never arise in determining the nature of the 
sediment, as a colored deposit appearing in an acid urine which dis- 
solves upon the application of heat cannot be due to anything but 
urates. If a drop of the sediment, moreover, is treated upon a 
slide with a drop of hydrochloric acid, characteristic whetstone- 
crystals of uric acid separate out, but the greater portion appears in 
the form of rhombic platelets. 

Calcium Oxalate. — This substance generally appears in urinary 
sediments in the form of colorless, highly refractive octahedra (Fig. 
105), which vary greatly in size; some appear as mere specks 
under even a comparatively high power, while others may attain 
the dimensions of a large leucocyte. Frequently one axis is 
longer than the other. From the fact that their diagonal planes 
are highly refractive, apparently dividing the superficial plane 
into four triangles, they have been compared to envelopes, and it 
is this envelope-form of the crystals which is especially character- 
istic. In the same specimen of urine so-called dumb-bell form- may 
be seen, which appear to be made up of two bundles of needle-like 



MICROSCOPICAL EXAMINATION OF THE URINE. 503 

crystals united in the form of the figure 8. These, according to 
Beale, originate in the uriniferous tubules, and are frequently found 
adherent to or imbedded in tube-casts. Other forms may also be 
seen, and are shown in the accompanying figure. 

While the envelope crystals are highly characteristic and can 
hardly be mistaken for any other substance, the student may at times 
confound them with crystals of ammonio-magnesium phosphate. 
This error may be avoided if it is remembered that the calcium oxa- 
late crystals are usually not so large as those of the magnesium salt, 
and that the latter dissolve upon the addition of acetic acid, in which 
calcium oxalate is insoluble. The distinction from uric acid, if we 
are dealing with the dumb-bell form, cannot always be made by 




o# 





Less common forms of calcium oxalate crystals. (Finlayson.) 

mere inspection. A drop of caustic soda should be added, which 
will dissolve the crystals if these are uric acid, while calcium oxalate 
remains unchanged. 

It has been pointed out that under strictly normal conditions a 
few isolated crystals of calcium oxalate may be found in the primi- 
tive nubecula, so that their presence in urinary sediments cannot be 
regarded as pathological. After the ingestion of certain vegetables 
and fruits, notably rhubarb, garlic, asparagus, and oranges, or follow- 
ing the continued administration of sodium bicarbonate or the salts 
of vegetable acids, calcium oxalate crystals may be observed in large 
numbers ; so also in ceftain diseases, such as diabetes mellitus, catar- 
rhal jaundice, phthisis, emphysema, etc. 

As in the case of uric acid, no inference as to the quantity 
eliminated can be drawn from a microscopical examination of the 
sediment. The frequent occurrence of abundant sediments of this 
substance may, however, generally be regarded as abnormal, pro- 
viding that such an occurrence cannot be explained by the nature 
of the diet. It is very suggestive to note the frequency with 
which such sediments are observed in cases of neurasthenia, asso- 
ciated with a mild degree of albuminuria, as also in various di- 



504 



THE URIXE. 



gestive neuroses. Finally, as with uric acid, the possibility of the 
formation of renal calculi should be borne in mind whenever abun- 
dant sediments of calcium oxalate are encountered upon frequent 
examination. 

Ammonio -magnesium phosphate, usually spoken of as triple phos- 
phate, crystallizes in large prismatic crystals of the rhombic system ; 

Fig. 106. 




Various forms of triple phosphates. (Finlayson.) 

it is most abundantly observed in alkaline urines, but may also occur 
in feebly acid specimens. Of the various forms which may occur, 
that resembling the lid of a German coffin is the most characteristic 
(Fig. 106). At times these crystals attain considerable size ; very 
small specimens, however, also occur which may be mistaken for 



Fig. 10; 




Crystalline phosphates. (Finlayson.) 



oxalate of calcium, but from these they are readily distinguished 
by the ease with which they dissolve in acetic acid, as has been 
pointed out. 

Here, as elsewhere, it should be remembered that no conclusions 



MirROSCOPICAL EXAMINATION OF THE URINE. 



505 



a> to the amount actually eliminated can be drawn from a micro- 
scopical examination, and the diagnosis " phosphaturia " should be 
based only upon the results of a quantitative analysis. 

The continued elimination of a turbid urine, the turbidity of which 
is referable to phosphates, is notably observed in neurasthenic indi- 
viduals with a predominance of cerebral symptoms. Very curiously, 
the phosphaturia is not influenced by diet. 

Monocalcium phosphate crystals are rarely seen, and only in speci- 
mens presenting a highly acid reaction, when uric acid crystals are 
also frequently observed in large numbers. I have seen only a few 
cases of this kind, occurring in patients the subjects of functional 
albuminuria. The urine was highly acid, in one case of a specific 
gravity of 1.036, and on standing deposited a sediment which con- 
sisted largely of monocalcium phosphate crystals (Fig. 108), with a 
considerable number of uric acid crystals, from which they are 



Fig. 108. 





Monocalcium phosphate crystals. 

readily distinguished by the absence of pigment and their solubility 
in acetic acid. 

Neutral Calcium Phosphate. — These crystals may be found in alka- 
line, neutral, and feebly acid urines. They are at times of large 
size, but more commonly acicular, occurring either singly or united 
in a star-like manner (Fig. 107). They are colorless, readily solu- 
ble in acetic acid, and insoluble in warm water, so that they can be 
easily distinguished from uric acid. 

Basic magnesium phosphate crystals occurring in the form of large, 
highly refractive plates (Fig. 109), are at times seen in alkaline, 
neutral, or faintly acid and highly concentrated urines. They are 
readily recognized by treating a drop of the sediment upon a slide 
with a drop of ammonium carbonate solution (1 : 4), when the crys- 
tals become opaque and their edges assume an eroded aspect. In 
acetic acid they dissolve with ease and may then be reprecipitated 
by means of sodium carbonate. 1 

1 Stein, Arch. f. klin. Mod., 1876, vol. xviii. p. 207. 



506 



THE URINE. 



Hippuric acid crystals have been observed, although rarely, in uri- 
nary sediments, in acute febrile diseases, diabetes, and chorea ; while 
their occurrence following the ingestion of large amounts of prunes, 
mulberries, blueberries, or the administration of benzoic acid and 
salicylic acid, is more common. 



Fig. 109. 




Basic magnesium phosphate crystals, (v. Jaksch.) 

Hippuric acid occurs in the form of fine needles or rhombic prisms 
and columns, the ends of which terminate in two or four planes, at 
times resembling the crystals of ammonio-magnesium phosphate and 
of uric acid. From the former they may be readily distinguished by 
their insolubility in hydrochloric acid, and from the latter by the 
fact that they do not give the murexid reaction when treated with 
nitric acid and ammonia (see page 377). In the case of urines rich 
in hippuric acid in which the substance does not appear in the sedi- 
ment, it is well to add a small amount of hydrochloric acid, when 
the crystals will gradually separate out. Their presence does not 
appear to possess any clinical significance. 

Calcium sulphate, in the form of long colorless needles or elon- 
gated prismatic tablets (Fig. 110), has been observed in urinary 

Fig. 110. 




Calcium sulphate crystals, (v. Jaksch.) 



sediments in only two cases. In both the urine, especially on 
standing, deposited a milky-looking sediment, the reaction being 



MICROSCOPICAL EXAMINATION OF THE URINE. 507 

strongly acid. It may be recognized by its insolubility in acids and 
ammonia. 1 

Cystin (C 6 H 12 ( S,) is rarely seen in urinary sediments. It occurs 
in the form of colorless hexagonal platelets, which are very charac- 
teristic (Fig. 111). The crystals are soluble in ammonia and hydro- 
chloric acid, and insoluble in acetic acid, water, alcohol, and ether. 

Fig. 111. 




Crystals of cystin spontaneously voided with urine. (Roberts.) 

They can thus be readily distinguished from certain forms of uric 
acid, with which they might possibly be confounded at first sight. 
When heated upon platiuum foil they burn with a bluish-green 
flame without melting. 

C ystin-containing urines may be of normal appearance, but they 
often present a peculiar greenish-yellow color. Their reaction is 
mostly neutral or alkaline. Upon exposure to the air a marked odor 
of hydrogen sulphide develops, owing to decomposition of the cystin ; 
but at times urines are met with in which a distinct odor of hydrogen 
sulphide is noticeable, although crystals of cystin are not seen in the 
sediment. It may then be demonstrated by strongly acidifying the 
urine with acetic acid or by allowing it to undergo ammoniacal decom- 
position. In either ease cystin crystals will separate out on standing. 
It should be remembered, however, that not all urines in which 
hydrogen sulphide i< formed contain cystin (see Ilydrothionuria). 

The amount of cystin which may be found in urinary sediments 
i- variable. Sometimes a few centigrammes only are obtained, while 
at others from 0.5 to 1 gramme may be recovered. As is the case 
with the other non-organ i/ed constituent- of* sediments, however, the 
amount deposited does not necessarily indicate the total amount 
1 v. Jaksch, Zeit. f. klin. Med., 1892, vol. xxii. p. 554. 



508 THE URINE. 

present. Where a quantitative estimation of eystin is to be made, 
it is best to filter off that which is deposited and to estimate the 
amount of neutral sulphur in the filtered urine. An increase beyond 
the normal may be referred to the eystin remaining in solution (see 
Neutral Sulphur). 

Clinical interest in connection with cystinuria centres in the fre- 
quent association of eystin sediments with eystin gravel or calculi ; 
but it is curious to note that the cystinuria, notwithstanding the 
removal of the calculus, may persist for years without giving rise to 
symptoms denoting the existence of a pathological process. 

Very remarkable is the not uncommon occurrence of cystinuria in 
families. Cases of transient cystinuria likewise occur, and it is 
hence scarcely admissible to speak of a " cured " cystinuria when 
the condition disappears under treatment. 

Of the origin of the condition little is known. It has been sup- 
posed that the appearance of eystin in the urine is in some manner 
connected with the formation of certain diamins in the intestinal 
canal. I have pointed out, however, that in all probability the for- 
mation of eystin and diamins takes place in the tissues of the body, 
and that the appearance of both is the expression of a definite meta- 
bolic anomaly rather than of a specific infection (see page 495). 

Literature. — C. E. Simon, "Cystinuria and its Relation to Diaininuria," Am. 
Jour. Med. Sci., 1900, vol. cxix. p. 39. See also the literature on page 498. 

Leucin and tyrosin belong to the group of amido-acids, and are 
represented by the formulae C 6 H 13 N0 2 and C 9 H n 3 . They are never 
found in urinary sediments under normal conditions, while traces of 
both substances may be present in solution. Larger amounts are 
notably found in acute yellow atrophy, of which disease their presence 
in sediments is almost pathognomonic. In acute phosphorus poison- 
ing leucin and tyrosin are usually not found. The fact that urea 
may be altogether absent from the urine in acute yellow atrophy or 
present in greatly diminished amount has been previously referred 
to (see Urea, page 345), and the elimination of leucin and tyrosin 
in its stead, as it were, has been regarded not only as indicating the 
probable origin of urea from amido-acids, but also the formation of 
urea, to a large extent at least, in the liver. The albuminous origin 
of these substances has also been noted (see Urea). 

Traces of leucin and tyrosin are said to be constantly present in 
cases of cirrhosis and carcinoma of the liver, in cholelithiasis, catar- 
rhal jaundice, Weil's disease, nephritis, cystitis, gout, bronchitis, 
tuberculosis, typhoid fever, hysteria, erysipelas, glucosuria, etc. In 
connection with cystinuria, the elimination of tyrosin has also been 
observed, but in two cases which I examined in this direction I 
obtained negative results. In diabetic urines both are supposedly 
absent. 



MICROSCOPICAL EXAMINATION OF THE URINE. 



509 



As leucin is hardly ever found in the sediment, and tyrosin only 
when present in large quantities, the urine in every case should first 
be concentrated upon a water-bath and examined on cooling. At 

times, however, when these substances are present in only very small 
quantities, this procedure may not lead to the desired end, and in 
doubtful eases the following method should be employed : 

The total amount of urine voided in twenty-four hours is pre- 
cipitated with basic lead acetate and filtered, when the filtrate, from 
which the excess of lead has been removed by means of hydrogen 
sulphide, is evaporated to as small a volume as possible, and is set 
aside for crystallization. The residue thus obtained is then examined 
with the microscope ; if crystals are detected which answer the 
description of tyrosin and leucin, they should be subjected to further 
chemical tests. 

Fig. 112. 




Tyrosin crystals. (Charles.) 



Ulrich advises to evaporate the urine to dryness and to heat the 
residue gently while the vessel is covered with a plate of glass or a 
funnel. The tyrosin is then said to sublime, and is deposited on the 
cool glass in crystalline form, the crystals giving the characteristic 
reactions. 

Tyrosin crystallizes in the form of very fine needles (Fig. 1 1 2), 
which are usually grouped in sheaves or bundles crossing each other 
at various angles. They are insoluble in acetic acid, but soluble in 
ammonia and hydrochloric acid. 

Leucin (Fig. 113) occurs in the form of spherules of variable size, 
which closely resemble globules of fat, but may be distinguished from 
these by their insolubility in ether. In the urine they present a 
more or less pronounced brownish color, and upon close examination 
concentric striations as well as very fine radiating lines can at times 
be made out, which are especially characteristic. 

If crystals resembling tyrosin and leucin are found, the following 
tests should be made : 

Tests for Tyrosin. — The sediment is filtered off, washed with 
water and dissolved in ammonia to which a little ammonium car- 



510 



THE URINE. 



bonate has been added. The solution is allowed to evaporate, when 
the tyrosin remains behind. 

Piria's Test. 1 — A bit of the tyrosin is moistened on a watch-crys- 
tal with a few drops of concentrated sulphuric acid, covered, and 
set aside for half an hour. It is then diluted with water, heated, 
and while hot saturated with calcium carbonate and the solution 
filtered. The filtrate is colorless, but when heated with a few drops 
of a very dilute solution of ferric chloride, which must be free from 
hydrochloric acid, it assumes a violet tint (v. Jaksch). 

Fig. 113. 




Crystals of leucin (different forms'*. (Crystals of kreatinin-zinc chloride resemble the 
leucin crystals depicted at a.) The crystals figured to the right consist of comparatively 
impure leucin. (Charles.) 



Hoffmann's Test. 2 — A small amount of tyrosin is dissolved in hot 
water and treated, while hot, with mercuric nitrate and potassium 
nitrite. The solution assumes a beautiful dark-red color and yields 
a voluminous red precipitate. 

Tests for Lettcix. — Seherer's Test. 3 — To test for leucin, this is 
separated from tyrosin by the addition of a little alcohol (see below). 
The alcohol is allowed to evaporate, and a portion of the residue 
treated upon platinum foil with nitric acid, when a colorless residue 
is obtained which, upon the application of heat and the addition of a 
few drops of a solution of sodium hydrate, forms a droplet of an 
oily fluid which does not adhere to the platinum. 

Hofmeister's Test. 4 " — A small amount of leucin dissolved in water 
causes a deposit of metallic mercury when heated with mercurous 
nitrate. 

In order to separate the leucin from the tyrosin, the sediment is 
treated with a small amount of alcohol, in which leucin is more 
readily soluble than tyrosin. 

Literature. — Frerichs, Wien. rued. Woch.. 1854, vol. iv. p. 465. Schnltzen u. 
Eiess, Charite Annal., vol. xv. Pouchet. Maly's Jahresber.. 1S80. vol. x. p. 24S. Irsai. 
Ibid., 1S85, vol. xiv. p. 451. Prus, Ibid.. 1888." vol. xvii. p. 345. Frankel. Berlin, klin. 
Woch., 1878, vol. xv. p. 265. 

1 Piria, Liebig's Annal.. 1852, vol. lxxxii. p. 251. 

2 Hoffmann. Ibid., 1857. vol. lxxxvii. p. 124. 

3 Scherer, Jour. f. prak. Chem.. 1887, vol. lvxix. p. 410. 

4 Hofrneister. Liebig's Annal., 1S77.. vol. cxxxix. p. 6. 



MICROSCOPICAL EXAMINATION OF THE URINE. 



511 



Zanthin crystals (Fig* 114) arc very rarely observed in urinary 
sediments, and, so far as 1 have beeD able to ascertain! the case 
observed by Bence Jones 1 is the only one on record, (arc should 
be had not to confound certain forms of uric acid with xanthin, 
and I well remember an instance in which crystals were observed 



Fig. ill. 




a, Crystals of xanthin (Salkowski) ; b, Crystals of cystin (Robin). 

identical in appearance with those here pictured, but which upon 
chemical examination proved to be uric acid. The necessity of disre- 
garding the statement generally made that uric acid crystals found in 
urinary sediments are invariably colored cannot be insisted upon too 
strongly. It has been stated elsewhere that colorless uric acid 

Ftg. 115. 




Lime and magnesium soaps, (v. Jak-< B.) 



crystals may be encountered, and in the case just cited such were 
observed. 

Clinically, xanthin sediments are of interest only in so far as this 
substance may give rise to the formation of calculi ; in the case 
observed by Bence Jones attacks of renal colic had occurred several 
years previously. 

1 Bence Jones, Clam. ('. ntralbl., 1868, vol. xiii. 



512 THE URINE. 

Soaps of Lime and Magnesia. — v. Jaksch has pointed out that 
in various diseases crystals may be found which " closely " resemble 
tyrosin in appearance, and pictures such crystals (Fig. 115), which 
from their behavior toward reagents he is inclined to regard as cal- 
cium and magnesium salts of certain higher fatty acids. 

Should doubt arise, the question may be readily decided by a 
chemical examination (see tests for tyrosin and fatty acids). 

Bilirubin crystals in the form of yellow or ruby-red rhombic plates 
or needles, as well as amorphous granules, have been seen in the 
urine in rare cases, but are of no special interest. They are easily 
soluble in alkalies and chloroform, but not in ether. When treated 
upon a slide with a drop of nitric acid a green ring will be seen to 
form around them (Gmelin's reaction). 1 Such crystals have been 
found in icteric urine and in a case of pyelonephritis. 

Haematoidin crystals are likewise only rarely seen. They cannot 
be distinguished from bilirubin, with which, indeed, they are sup- 
posedly identical. 2 They may be found either free or imbedded 
within cells or tube-casts, in cases of scarlatinal nephritis, the 
nephritis of pregnancy, in granular atrophy, amyloid degeneration 
of the kidneys, and in carcinoma of the bladder, of which latter 
condition they have been regarded by some as pathognomonic. 

Fat. — When small, strongly refractive globules of fat, which may 
be readily recognized by their solubility in ether, are observed either 
floating on the urine or held in suspension, it is necessary to ascer- 
tain first of all whether such fat may not be present accidentally, 
owing to the use of a bottle or vessel not absolutely clean, or 
previous catheterization, etc. The diagnosis lipuria should only 
be made when all possible precautions have been taken to insure 
against the accidental presence of this substance. Every phy- 
sician who has frequent occasion to examine urines has undoubtedly 
met with instances in which fat-globules were found, and in 
which careful inquiry showed that these were accidentally present. 
True lipuria — i. <?., an elimination of fat usually in the form of 
droplets floating on the urine — has been noted in various cachectic 
conditions, in cases of heart-disease, affections of the pancreas 
and liver, in gangrene and pyaemia, in diseases of the bones, 
especially following fractures, in diseases of the joints, etc. Fat 
has also been observed in the urine following the ingestion of 
large amounts of cod-liver oil and inunctions with fats and oils. 

In fatty degeneration of the kidneys, in Bright' s disease, phos- 
phorus poisoning, etc., droplets of fat may be seen in the epithelial 
cells and tube-casts. This, however, does not constitute lipuria. 
The nature of the droplets may be recognized by their solubility in 

1 Kussmaul, Wiirzburger med. Zeit., 1863, vol. iv. p. 64. Ebstein, Arch. f. klin. 
Med., 1879, vol. xiii. p. 115. 

2 Hoppe-Seyler u. Thierfelder, Handb. d. physiol. u. path., chem. Analyse. 



MICROSCOPICAL EXAMINATION OF THE URINE, 513 

ether, benzol, chloroform, carbon disulphide, xylol, etc., and by t lie 
fact that they arc colored black when treated with a 0.5 to 1 per 
cent, solution of osmic acid, and red when a drop of tincture of 

alcanna is added to the specimen. A very convenient method of 
demonstrating the presence of fat is also the following: a few 
cubic centimeters of the urine are mixed with an equal volume of 
!'<; per cent, alcohol and a concentrated solution of Sudan III. in 
96 per cent, alcohol. The sediment which collects is then ex- 
amined under the microscope; the excess of stain is removed by 
allowing a few drops of 60 or 70 per cent, alcohol to run under 
the cover-slip and removing it with filter-paper placed at the 
edge of the preparation. The fat-droplets are thus colored 
an intense scarlet red, while granules of albuminous origin are 
unstained. Free fat can, of course, be demonstrated in the same 
manner. 

The largest amounts of fat are observed in chyluria, a condition 
which is usually due to the presence of a specific parasite in the 
blood, viz., the Filaria sanguinis hominis, or more rarely the Distoma 
haematobium, which have been described in the chapter on the Blood 
(see also Chyluria). 

Sediments occurring in Alkaline Urines. — Basic Phosphate of 
Calcium and Magnesium. — The most common sediments observed in 
alkaline urines consist of amorphous phosphates of calcium and 
magnesium. They are usually as abundant as the urate sediments 
which have been described, but may be readily distinguished from 
these by the fact that they do not dissolve upon the application of 
heat, but readily disappear upon the addition of acetic acid, and are 
never colored. In this manner it is also easy to distinguish such a 
sediment from one due to pus, with which it might possibly be con- 
founded at first sight. Upon microscopical examination a drop of 
the sediment will be seen to contain innumerable transparent granules 
scattered over the entire field, and closely resembling those of urate 
of sodium and potassium. 

Phosphatic sediments are observed, as mentioned elsewhere, when- 
ever the reaction of the urine is alkaline, whether this be owing to 
the presence of fixed alkali or to ammoniacal fermentation. 

Ammonium urate is observed only in urines which arc undergoing 
ammoniacal decomposition. Its presence should always call for a 
careful investigation in order to ascertain whether this has taken 
place after the urine has been voided or before (see Reaction). 

The salt occurs in the form of colored spherical bodies of variable 
size, which are sometimes composed of delicate needles, while at 
others they are amorphous, but may be beset with prismatic spicules* 
They are not easily mistaken for any other substance which may be 
present in urinary sediments (Fig. 116). Ammonium unite is 
characterized, moreover, by its solubility in acetic and hydrochloric 



514 THE UBIXE. 

acids, and by the subsequent separation of rhombic crystals of uric 
acid. 

Magnesium phosphate has been described above (see page 505). 

Am monio -magnesium Phosphate. — While the well-known coffin-lid 
crystals are commonly seen in feebly acid urines, as pointed out, 
ammonio-magnesium phosphate presents a great variety of forms in 
alkaline urines, and especially in specimens undergoing ammoniacal 
decomposition (see Fig. 107). 

Fig. 116. 




Ammonium urate crystals. 



Calcium carbonate frequently occurs in alkaline urines, and appears 
under the microscope in the form of minute granules, occurring 
singly or arranged in masses ; dumb-bell forms are also seen (Tig. 
117). They may be recognized by the fact that they readily dis- 
solve in acetic acid with the evolution of gas. 



Fig. 117 




k - 



!<V- 



Calcium carbonate crystals. 

Indigo in the form of delicate blue needles (Plate XYIIL). ar- 
ranged in a stellate manner or in plates, visible only with the micro- 
scope, is rarely seen, and a specimen such as the one which v. 
Jaksch pictures can be regarded only as a medical curiosity. In an 
amorphous condition, however, indigo may be met with in almost 



PLATE XV 




Indigo Crystals from a Urine Rich in Indiean, after standing for Eight Days 
at Ordinary Temperature. (V. Jaksch.) 



MICROSCOPICAL i:\AMlNATION OF THE URINE. 



515 



every decomposed urine, occurring in the form of small granules, 
and frequently staining the morphological elements that may he 
present a distinct blue. Sediments presenting a bluish-black color 
were noted in the time of Hippocrates already, and have been 
described since by numerous observers, but the nature of the color- 
ing-matter has only been determined within the last fifty years. 
Clinically, the occurrence of indigo in the urine is of interest, as 
renal calculi have been observed which consisted almost entirely of 
this substance. But little is known of the causes which give rise 
to its appearance in the urine, but there can be no doubt that its 
occurrence is referable to the action of certain micro-organisms 
upon urinary indican (see page 494 j. 1 

Organized Constituents of Urinary Sediments. 

Epithelial Cells (Fig. 118). — Bearing in mind the fact that 
desquamative processes are constantly going on in the epithelial 

Fig. 118. 




Epithelium from the urinary passages. 
a, Round cells ; b, conical and caudate cells ; c, flat cells. 



lining of the various cavities and channels of the body, one -hould 
expect to find in every urine representatives of the different forms 

1 v. Jaksch, Prag. nied. Woch., 1892, vol. xvii. p. 602. 



516 THE URINE. 

of epithelium occurring in the urinary organs, from the Malpighian 
tufts down to the meatus urinarius. To a certain extent this actu- 
ally happens, and cells apparently derived from the meatus, the 
urethra, bladder, ureters, and pelvis of the kidneys may be met with 
in almost every specimen, although it may at times be difficult to 
refer to their origin the individual cells observed. Bizzozero even 
claims that it is impossible to distinguish between the cells of 
the bladder and those of the meatus and renal pelvis, while as a 
class they may readily be differentiated in most cases from the cells 
of the urethra, the ureters, the prepuce of the male, and the vulva 
and vagina of the female. Cells from the uriniferous tubules of the 
kidneys are seldom seen in normal urines, and when they do occur 
it is impossible to determine their exact origin — i. e., the particular 
portion of the tubule from which they have been detached. Cells 
presenting the characteristic striated appearance seen in the irregu- 
lar, and to a less evident degree in the convoluted, portions of the 
uriniferous tubules, are never observed in the urine. This fact, as 
well as the usual absence of true glandular cells, remains to be 
explained. It is not improbable that the absence of these cells may 
be referable to a less marked desquamation going on in those parts 
in which the mechanical injury to which the epithelium is subject 
must of necessity be far less severe than in the remaining portions 
of the urinary tract, and particularly in the bladder and urethra. 

As stated elsewhere, the number of epithelial cells occurring in 
urinary sediments under physiological conditions is small, and the 
presence of large numbers may hence always be regarded as abnormal, 
and indicating the existence of a circulatory or inflammatory dis- 
turbance affecting some portion of the urinary tract. 

Were it possible in every case to determine the exact origin of 
the cells, it is evident that information of great value would thus 
be obtained. Unfortunately, this is not always possible, as the 
form of the cells is dependent to a certain extent upon the reac- 
tion of the urine, an alkaline or neutral reaction causing the cells 
to swell and to appear larger and rounder than is the case in acid 
urines. As has been mentioned, the cellular type is practically the 
same, moreover, in the bladder, ureters, and pelvis of the kidneys. 

Definite conclusions should hence be drawn only exceptionally 
from a microscopical examination alone, but there can be no doubt 
that in conjunction with other factors and the clinical history the 
demonstration of a normal or increased number of epithelial cells 
may frequently be of decided value in a differential diagnosis, and 
taking these factors into consideration it may even be possible to 
localize the seat of the lesion. If attention is directed to the struct- 
ure of the individual cell — and this holds good more especially for 
the cells derived from the uriniferous tubules — an idea may at times 
even be formed of the character of the lesion (see below). 



MICROSCOPICAL EXAMINATION OF THE URINE. 517 

Ultzmann recognizes three forma of epithelial cells which may be 
found in urinary sediments, viz.: 

1. Round cells. 

2. Conical and caudate cells. 

3. Flat cells. 

Round cells are usually derived from the uriniferous tubules and 
the deeper layers of the mucous membrane of the pelvis of the kid- 
neys. In the urine they present a more or less rounded form and 
are provided with a distinct nucleus ; they are not much larger than 
pus-corpuscles. From the latter they are distinguished by the pres- 
ence of a well-defined nucleus, which in pus-cells becomes distinct 
only upon the addition of acetic acid, and is, moreover, polymor- 
phous. Whenever such cells are found adhering to urinary casts, 
which may at times consist entirely of these structures, it is clear 
that they represent the glandular elements proper of the kidneys. 
A- similar cells are found in the male urethra, confusion may 
possibly arise. Should albumin, however, be present, the cells are 
pmbably of renal origin. The presence of such cells in large 
numbers together with pus, in the abseuce of tube-casts aud 
albumin beyond traces, will usually indicate the existence of a 
simple pyelitis, particularly if round cells are found joined in a 
shingle-like manner. Should the pyelitis be associated with a ne- 
phritis, tnl u '-casts and albumin in larger amounts will at the same 
time be present. In such cases it may be impossible to determine 
the origin of the cells, excepting of such that may adhere to casts. 
In simple circulatory disturbances affecting the renal parenchyma 
no special abnormalities can be discovered in the structure of the 
cells, while in cases of fatty degeneration of the kidneys they will 
be seen to contain fatty particles in greater or less abundance, so 
that it may be possible to determine the existence of degenerative 
processes which may be of inflammatory or non-inflammatory origin. 
The same may be said to hold good if the epithelial elements are 
markedly granular and occur in fragments. 

Conical and caudate cells are mostly derived from the superficial 
la vers of the pelvis of the kidneys, and are hence especially seen in 
cases of pyelitis. Similar cells are also found in the neck of the 
bladder, and may usually be distinguished from those of the pelvis 
by the greater length of their processes. 

Flat cells may come from the ureters, the bladder, the prepuce of 
the male, and the vulva and vagina of the female. These cells pre- 
sent the usual characteristics of squamous epithelium, being large, 
polygonal in form, and provided with a well-defined nucleus ; the 
extra-nuclear protoplasm i- only -lightly granular. Other more or 
less rounded forms are also seen, which are derived from the deeper 
layers of the mucosa, but may be distinguished from the small 
round cells of the kidney- proper. Irregular or conical cells, often 



518 THE URINE. 

provided with one or more protoplasmic processes, likewise come 
from the lower layer of the mucosa of the bladder and ureters. 

While the cells of the bladder may thus be confounded with those 
of the ureters and vagina under the microscope, it is not likely that 
a vaginitis or vulvitis will be mistaken for a cystitis or a ureteritis. 
In doubtful cases specimens of urine should be procured by means 
of the catheter, care being taken to first thoroughly cleanse the vulva. 
The warped appearance so frequently seen in vaginal epithelial cells, 
and the fact that they often and indeed usually appear in masses, 
may further aid in the differential diagnosis. 

It has been pointed out by Peyer that the presence of pavement- 
epithelial cells, together with mucus and leucocytes, in the mine of 
hysterical and anaemic girls may be regarded as indicating an irrita- 
ble condition of the genitals, possibly in consequence of masturba- 
tion. Bearing in mind the moist and sensitive condition of the 
vulva of female masturbators, such a view is plausible. 

A ureteritis, notwithstanding the fact that the ureteral cells 
closely resemble those of the bladder, may be inferred indirectly, 
the presence of squamous cells in abundance pointing to a cystitis, 
a small increase in their number to ureteritis. In conclusion, it 
should be stated that the so-called mucous corpuscles present in 
every urine are young vesical cells. 

From what has been said, it is clear that, with due precautions 
and taking other factors into consideration, the discovery of epi- 
thelial cells in large numbers in urinary sediments may he of decided 
value in diagnosis. 

Liteeatuee. — Bizzozero, loc. cit. Eichhorst, Lelirtraeh d. physiial. Untersmeh. 
inn. Krankheit., 2d ed.. p. 336. Braunschweig. 

Leucocytes. — Leucocytes are encountered in only very small 
numbers in normal urines. A marked increase should, hene-r. alws - 
be regarded as indicating the existence of disease somewhere in the 
course of the urinary tract, excepting in females, where their presence 
may be owing to an admixture of leucorrhoeal discharge. In that 
case the source of the pus will generally be recognized bv the simul- 
taneous occurrence of pavement epithelial cells of the vaginal type 
in correspondingly large numbers. In doubtful cases the urine 
should always be obtained with the catheter, care being taken to 
thoroughly cleanse the vulva before the introduction of the instru- 
ment. 

Occasionally the pus is derived from a neighboring abscess that 
has opened into the urinary passages. 

The amount of pus which may be found in urines is most varia- 
ble. On the one hand, deposits several centimeters in height arc : : 
uncommon, and closely resemble deposits of phosphates in appear- 
ance, for which they are indeed frequently mistaken ; on the other 



MICROSCOPICAL EXAMINATION OF THE URINE. 519 

hand, it may only be possible to discover the presence of pus by 
means of the microscope, which should be employed in every case. 

The appearance of the pus-corpuscles likewise varies in different 
cases. In acid urines their form is usually well preserved, and in 

feebly alkaline and neutral specimens it may even be possible to 
observe amoeboid movements when the slide is carefully wanned. 
In alkaline urines, however, they usually swell up and become 
opaque, so that it is impossible to discern a nucleus unless they 
are treated with acetic acid. At other times, and particularly when 
pus has remained long in the body, as where an abscess has burst 
into the urinary passages, it may be almost impossible to make out 
a nucleus, and in extreme instance- nothing but a mass of granular 
and fatty detritus is left. 

While with a certain amount of experience it is hardly likely that 
a sediment of pus will be mistaken for anything else, such as a 
deposit of phosphates, it should be remembered that if pus i< 
exposed to the action of ammonia or an ammonium salt the pus- 
corpuscles become disintegrated. In such cases, as in cystitis, in 
which ammoniacal decomposition of the urine has taken place in the 
bladder, a deposit may be obtained Avhich macroscopically resembles 
mucus, and in which pus-corpuscles may not even be demonstrable 
with the microscope. The sediment then escapes as a gelatinous, 
slippery mass when the urine is poured from one vessel into an- 
other. Recourse must then be had to certain chemical tests, as a 
pyuria might otherwise be overlooked. To this end, the following 
procedure, suggested by Vitali, 1 may be employed : 

The urine, after having been acidified with acetic acid, is filtered, 
and the contents of the filter treated with a few drops of tincture 
of guaiacum which has been kept in the dark, when in the pres- 
ence of pus the filter-paper is colored a deep blue. The reaction is 
supposedly due to the presence in the leucocytes of specific nucleo- 
proteid<. 

A solution of iodo- potassic iodide may be employed in less 
extreme instances. A drop of this solution is added to a drop of 
the sediment upon a slide, when the pus-corpuscles, owing to the 
presence of glycogen, are colored a dark mahogany-brown, while 
epithelial cells, with certain forms of which they might possibly be 
mistaken, assume a light color. 

Donnas pus-Jest is based upon the fact that the transformation of 
pus into a gelatinous, mucus-like mass, observed in cases of cystitis, 
owing t<> tlw action of ammonium carbonate, may also be artificially 
produced by the addition of a small piece of caustic soda and stir- 
ring, when in the presence of pus in small amounts the liquid 
becomes mucilaginous and ropy, while a gelatinous mass i- obtained 
if it is abundant. 

1 Vitali, Maly's Jahresber., 1*90, vol. xviii. p. 32fi. 



520 THE URINE. 

From a clinical point of view it is most important to establish the 
source of the pus in every case of pyuria. This may at times be 
difficult, but the following data will be found of value in a differen- 
tial diagnosis : 

1. In diseases affecting the renal parenchyma the amount of pus, 
as a rule, is small, except where a large abscess located in the kidney 
structure proper has suddenly burst into the pelvis of the kidney. 

In uncomplicated cases it is a comparatively easy matter to recog- 
nize the renal origin of the pus, as other constituents, such as renal 
epithelial cells, and especially tube-casts, are usually present at the 
same time, and, as was noted in the case of renal epithelial cells, 
leucocytes are frequently found adhering to the tube-casts, and at 
times apparently compose these entirely, when they are spoken of 
as pus-casts (see Casts). In nephritis, according to Bizzozero, the 
number of pus-corpuscles stands in a direct relation to the intensity 
and acute character of the morbid process, the greatest number 
being found in cases of acute nephritis, while in the chronic forms 
their number is usually insignificant. Whenever in the course of a 
chronic nephritis large numbers of pus-corpuscles appear, they may 
be regarded as indicating either an acute exacerbation of the disease 
or a complicating inflammation of some portion of the urinary tract. 
In such cases errors may be guarded against by carefully observing 
the number and character of the epithelial cells present at the same 
time, when it will often be found that what at first sight appears as 
an acute exacerbation of a chronic process, judging from the number 
of pus-corpuscles, is in reality a secondary pyelitis, ureteritis, or 
cystitis. 

In cases of simple renal hypersemia pus-corpuscles never occur in 
notable numbers. 

2. In pyelitis the amount of pus eliminated may vary consider- 
ably, and at times even perfectly normal urine may be voided. This 
is probably owing to the fact that the ureter of the affected side, if 
the disease is unilateral, becomes obstructed temporarily, when sud- 
denly large quantities may again appear. The diagnosis of pyelitis 
is often difficult, and should be based not only upon the condition of 
the urine, but upon the clinical symptoms as well. Very significant 
is the fact that the urine in pyelitis is usually acid, a point to be 
remembered in the differential diagnosis between this condition and 
cystitis, with which pyelitis is frequently confounded. A careful 
examination of the epithelial elements may also be of value, and 
should never be neglected. Bacteria in large numbers are generally 
present. 

When pyelitis is associated with nephritis it may at times be 
almost impossible to determine the origin of the pus ; but if the rule 
set forth above is remembered, that in chronic nephritis the number 
of leucocytes is always small, it is not likely that a pyelitis will be 



MICROSCOPICAL EXAMINATION OF THE URINE. 521 

overlooked, particularly if the clinical symptoms are taken into 
consideration. 

Matters may become still more complicated when a cystitis is 
accompanied by a pyelitis or a pyelonephritis. Catheterization of 
the meter-, which was first practised in the United States by the 
late Dr. James Brown, should then he resorted to, and it is highly 
desirable that this most valuable method of diagnosis should become 
common property a- soon as possible. Fischl regards the presence 
ot* cylindrical masses composed of pus-corpuscles, formed in all 
probability in the papillary ducts, as highly characteristic of pyelitis. 

3. A pyuria referable to ureteritis can hardly be diagnosed from 
the appearance of the urine, and in suspected cases catheterization of 
the ureters should be resorted to, which may possibly elicit informa- 
tion of value. 

4. In mild cases of cystitis pus may be altogether absent, while 
in the more severe forms its presence is constant. In cystitis the 
largest amounts, referable to disease of the urinary organs, are 
observed, and are exceeded only in those rare conditions in which 
a neighboring abscess has suddenly opened into the urinary pas- 
sages. 

As the urine in cystitis is usually alkaline, and always so in the 
more severe forms, the alkalinity being due to ammoniacal fermen- 
tation, it may happen, owing to the disintegrating action of the 
ammonium carbonate upon the pus-corpuscles, that these may not 
even be demonstrable with the microscope, and that a gelatinous, 
mucoid sediment appears instead, which escapes from the vessel < n 
masse when the urine is poured out. Yitali's test for pus (referred 
to on page 579) should be employed in such cases. 

5. In urethritis pus may be present in the urine in considerable 
amounts. The source of the pus is recognized by the fact that a 
drop may be manually expressed from the urethra, particularly in 
the morning upon awaking. Mucoid gonorrhoea! threads, — the 
" Tripperfaden " of the Germans, — which are largely composed of 
pus- corpuscles, will almost always be detected in the urine in such 

3 (Fig. 129). In order to distinguish between a simple urethritis 
and a urethritis complicated with cystitis, the urine should be 
obtained in two portions and allowed to settle. In simple urethritis 
affecting the anterior portion of the urethra the first specimen is 
cloudy, while the second one is clear. If the urethritis, however, 
has extended to the neck of the bladder, in the absence of cystitis, 
the first portion will, of course, be cloudy, while the second may 
present a variable appearance, being clear at times and cloudy nt 
others. This phenomenon is explained by the fact that a portion of 
the pus contained in the posterior portion of the urethra has found 
its way into the bladder. A cystitis may, however, be excluded by 
the acid reaction of the second specimen, and the fact that the latter 



522 THE URINE. 

is never so cloudy as the first. In cases of urethritis complicated 
with a purulent cystitis the second portion of the urine contains at 
least as much pus as the first, and usually more, owing to the fact 
that the pus (which is heavier than the urine) falls to the floor of the 
bladder, in which case also the last drops passed will often be found 
to be pure pus. The reaction of the urine, moreover, will then 
be generally alkaline. 

6. A sudden elimination of large quantities of pus with a urine 
which up to that time has presented a normal or nearly normal ap- 
pearance may almost always be referred to rupture of an abscess into 
the urinary passages. Exceptions to this rule have been noted in 
rare instances in which large amounts of pus suddenly appeared, the 
origin of which could not be demonstrated upon post-mortem inves- 
tigation. Whether such a phenomenon, as v. Jaksck suggests, is 
dependent upon " unusual conditions favoring diapedesis " remains 
an open question. 

Enumeration of the Pus-corpuscles in the Urine. — In order to 
determine the relation existing between the degree of pyuria and 
albuminuria, as well as to watch the progress of an individual case, 
an enumeration of the number of pus-corpuscles is at times neces- 
sary. To this end, a specimen of the urine is thoroughly shaken 
and the number of corpuscles contained in one cubic millimeter 
ascertained with the aid of the Thoma-Zeiss blood-counter. Dilu- 
tion with a 3 per cent, solution of common salt is necessary when a 
preliminary examination has shown the presence of more than 40,000 
corpuscles per cbmm. A dilution of five times is usually sufficient. 
In every case one hundred squares at least should be counted. 

Some of the results which have thus been obtained are extremely 
interesting. In cases of mild cystitis 5000 pus-corpuscles are found 
on an average in the cubic millimeter ; in cases of moderate severity 
from 10,000 to 20,000 ; while in severe cases 50,000 and even more 
may be seen. In one case of cystitis complicating carcinoma of the 
bladder Hottinger obtained 152,000 per cbmm. In the presence of 
less than 50,000 a mere trace of albumin is found, and with 80,000- 
100,000 only 1 pro mille is referable to this source. 1 

Red Blood- corpuscles. — The presence of red blood-corpuscles in 
the urine, constituting the condition usually spoken of as hcematuria, 
is observed only in pathological conditions, and is, in contradistinc- 
tion to hemoglobinuria (which see), a very common occurrence. 

Urine containing blood-corpuscles in notable numbers presents a 
color which mav vary from a bright red to a dark brown verging 
upon black. Upon standing, a sediment of a corresponding color 
is obtained in which distinct coagula of variable size are at times 
seen. 

1 E. Wunderlich. Ueber d. Werth d. Zahlung d. weissen Blutkorperchen im Ham, 
etc., Diss.. Wurzbnrg, 1885. 



MICROSCOPICAL EXAMINATION OF THE URINE. 523 

It' the urine should contain only a small Dumber of red corpuscles, 
however, do deviation from its normal appearance will be noted, and 
the diagnosis of hematuria can then only be made with the micro- 
scope, which should be employed in every case. The appearance "1" 
the red corpuscles varies greatly, being influenced especially by the 
length of' time during which they have remained in the urine. In 
cases of luematuria of urethral or vesical origin it will he found 
that they have mostly retained their normal appearance fairly well, 
or have become erenated, when they may be recognized without diffi- 
culty. Other corpuscles, however, will probably also be seen which 
are no longer biconcave, but which have become spherical or shrunken 
and present an irregular outline. In cases, on the other hand, in 
which the corpuscles have remained in the urine for a longer time, 
as in hematuria of renal origin, the inexperienced will frequently be 
puzzled by the presence of bodies of the size of red corpuscles, or 
somewhat smaller, which are entirely devoid of coloring-matter, and 
appear as faint, transparent rings, often presenting a double contour, 
and in which no nucleus can be discovered. These formations are 
red blood-corpuscles from which the haemoglobin has been dissolved. 
They are usually spoken of as blood-shadoics. Chemical tests are 
rarely necessary, but may be employed if doubt should arise (see 
page 4*29). 

Clinically it is, of course, all-important to determine the source of 
the blood. This may at times be accomplished without much diffi- 
culty by a urinary examination, but at other times it may almost be 
impossible, "when the clinical symptoms and physical signs must be 
taken into consideration. 

1. Hematuria of urethral origin, due to urethritis or traumatism 
incident to catheterization, for example, is a common event, and 
readily diagnosed, as in such cases blood either escapes of itself 
from the urethra or it may be squeezed out manually. The last 
portion of the urine voided, moreover, will always be found free 
from blood, unless it is referable to disease of the neck of the bladder, 
when the blood appear- only toward the end of micturition, or at 
least more markedly then than in the beginning. 

2. The diagnosis of vesical hematuria is not always easily made. 
It should be remembered, however, that the blood-corpuscles here 
present a normal appearance. ;i- has been mentioned, unless animo- 
niacal decomposition is occurring in the bladder, in which case blood- 
shadows are seen in large numbers. The blood, moreover, Is less 
intimately mixed with the urine than in cases of renal hematuria, 
so that the corpuscles rapidly settle after the urine has been passed. 
Blood-clots of an irregular form and considerable dimensions can 
only be of vesical origin. A careful examination for the presence 
of any other morphological constituents which may be observed in 
urinary sediments, when considered in conjunction with the clinical 



524 THE URINE. 

symptoms, will usually lead to a correct diagnosis so far as the seat 
of the hemorrhage is concerned. Haematuria of vesical origin mav 
be due to numerous causes, among which may be mentioned diph- 
theritic cystitis, ulcers of the bladder caused by calculi and carci- 
noma, traumatism, the presence of parasites, and, more rarely, rupture 
of varicose veins in the bladder. In determining the cause of the 
hemorrhage in a given case more reliance should be placed upon the 
clinical history than upon the urinary examination. 

3. In hematuria of ureteral origin characteristic blood-coagula, 
corresponding in diameter and form to the ureters, are occasionally 
seen. Their presence, however, does not necessarily indicate that 
the blood has come from the ureters ; more frequently the hemor- 
rhage will be found to be due to disease of the pelvis of the kidney. 

4. The diagnosis of hemorrhage into the pelvis of the kidney 
must be based upon the clinical symptoms taken in conjunction with 
the results of a urinary examination. In nephrolithiasis only a small 
number of red corpuscles is usually found, which is important from 
the standpoint of differential diagnosis. 

5. Haematuria of purely renal origin is of common occurrence, and 
may be due to numerous causes. In simple hyperaemic conditions of 
the organs and in acute nephritis the passage of smoky-looking urine 
containing blood-corpuscles, usually in large numbers, is thus a fairly 
constant symptom. In chronic nephritis the number of the red cor- 
puscles may be taken to indicate the intensity of the morbid process. 
Haeinaturia may also be due to renal abscess, nephrophthisis, renal 
carcinoma, and, in rare instances, to aneurism and embolism of the 
renal artery, thrombosis of the renal vein, etc. In the malignant 
forms of the acute infectious diseases, such as small-pox, yellow 
fever, malaria, etc., in scurvy, haemophilia, and purpura, in leukaemia, 
filariasis, and distomiasis, renal haematuria is common. It is also 
observed in cases of poisoning with turpentine, carbolic acid, can- 
tharides, etc. 

6. An idiopathic form of hematuria has also been described, in 
which hemorrhage from the kidneys occurs without apparent cause. 
To this form Senator applied the term " renal haemophilia." I have 
seen three cases of this kind in which no lesion existed which could 
be made responsible for the hemorrhage. In all three the attacks of 
haematuria were invariably associated with anachlorhydria, while 
normal values were found between the attacks. Two of the patients 
were males, and undoubtedly neurasthenics. The third was a hys- 
terical chlorotic female, in whom haematemesis, pulmonary hemor- 
rhages, and melaena were also at times observed. 

Haematuria of renal origin is usually recognized without much 
difficulty, as in such cases tube-casts bearing red blood-corpuscles, 
and at times apparently consisting of these altogether, as well as 
numbers of renal epithelial cells, will usually be found upon careful 



MICROSCOPICAL EXAMINATION OF THE URINE. 525 

examination. The blood, moreover, is intimately mixed with (lie 
urine, and the individual corpuscles have mostly lost their hemoglo- 
bin and appear as mere shadows. The clinical history should, of 
course, always he taken into consideration, especially in determining 
the primary cause of the hemorrhage. 

Trine containing red blood-corpuscles is always albuminous, so 
that it may sometime- he difficult to decide in a given ease whether 
the albumin found is due solely to the presence of Mood or whether 
the hematuria is complicated with an albuminuria per se. Fre- 
quently it i- possible to arrive at some conclusion by comparing the 
amount of albumin with the number of the red corpuscles, the 
presence of a large amount of the former in the presence of only a 
-mail number of the latter indicating that the albumin is not alto- 
gether due to the blood. At other times it is impossible to gain 
information in this manner, when the only expedient left is to deter- 
mine the quantity of albumin and of iron separately, and to ascertain 
whether the amount of iron found is sufficient to combine with that 
of the albumin. As a rule, however, the presence of serum-albumin, 
aside from that contained in the blood of the urine, may be inferred 
whenever tube-casts are present, although the amount can only be 
estimated approximately in this manner. 

Tube -casts. — In various pathological conditions, and it is claimed 
even in health, curious formations are seen in the urine, which repre- 
sent moulds of different portions of the uriniferous tubules. To these 
the term tube-casts or urinary cylinders has been applied, and it may 
be said that there is hardly a subject of greater importance in urinary 
analysis, from a clinical point of view, than that of eylindruria ; but 
it must also be admitted that notwithstanding numerous investiga- 
tions our knowledge of their nature and mode of formation is still 
defective, and the same may be said of their clinical significance. 
The term " tube-casts," however, is not altogether appropriate, as it 
is applicable to only one great division of such formations — i.e., to 
those consisting of a uniform, transparent, gelatinous matrix, to 
which other elements, such as epithelial cells, red blood-corpuscles, 
leucocyte-, and salts in a crystalline or amorphous form, may acci- 
dentally have become attached — the tube-casts proper. 

Prom these the so-called " pseudocasts " must be sharply differ- 
entiated, a pseudocast being characterized essentially by the absence 
of a uniform matrix. Closely related apparently to the true casts are 
the so-called cylindroids — i.e., band-like formations which resemble 
the former in appearance, and like these may carry various morpho- 
logical element- as well as -alts. It is thus necessary to distin- 
guish between true casts, pseudocasts, and cylindroids. Of these, 
the true casts are by far the most important. They may be 
divided into hyaline and waxy casts, the two forms being readily 
differentiated by the fact that the former readily dissolve in 



526 THE URINE. 

acetic acid, while the waxy casts are either not affected at all by this 
reagent, or, if so, at least not so rapidly. The latter, moreover, are 
more strongly refractive, to which property their waxy appearance 
is due ; their color is slightly yellow or yellowish gray, while the 
hyaline casts are colorless and usually very pale and transparent. 1 

Mode of Examination. — Unless a urine can be examined within 
a few hours after beiug voided, it is well to add a small amount of 
chloroform, so as to guard against bacterial decomposition. The use 
of conioal glasses is unsatisfactory, and I find it more convenient 
to keep the urine in well-stoppered bottles. Preserved with chloro- 
form it will keep almost indefinitely. Where a centrifugal machine 
is available the specimen can, of course, be examined at once. As 
soon as a sufficient amount of sediment has been obtained, a few 
drops are spread on a slide and examined, uncovered, with a low 
power. It is essential, however, to make use of the flat mirror and 
to avoid a bright light. If this is borne in mind, no difficulty what- 
ever will be found in demonstrating even the most hyaline specimens, 
though they may be present in very small numbers. In many text- 
books on urinary analysis the writers speak of the difficulty at- 
tending the search for hyaline casts, and the advice is frequently 
given to color the preparations with a drop of a dilute aqueous solu- 
tion of iodo-potassic iodide, or of some other staining reagent, such 
as gentian -violet, picrocarmin, methylene-blue, or osmic acid. This 
is unnecessary if the directions just given are strictly followed. If 
a bright light is used, however, I am willing to admit that even the 
most experienced examiner may be unsuccessful in his search. 

For the preservation of mounted specimens the following method, 
devised by Kronig, may be employed, though I personally prefer to 
keep the urine itself and to mount a fresh specimen when necessary. 
A drop of the sediment, best obtained by centrifugation, is spread 
on a cover-glass and allowed to dry in the air. It is then placed 
in a 10 per cent, solution of formalin, for ten minutes, rinsed in 
water, and stained for about ten minutes in a concentrated solution 
of Sudan III. in 70 per cent, alcohol. The excess of stain is 
removed by immersion for one-half to one minute in 70 per cent, 
alcohol, when the specimen is counter stained with Ehrlich's hema- 
toxylin, rinsed in water, and mounted in glycerin. Evaporation is 
guarded against by ringing the specimen with asphaltum. The 
tube-casts are thus stained a more or less pronounced blue, the 
nuclei of the leucocytes dark blue, aud any fatty granules or needles 
of fatty acids that may be present a bright red. 

True Casts. — 1. Hyaline Casts (Fig. 119). — Upon careful ex- 
amination it will be seen that with rare exceptions the matrix of 
hyaline casts is not altogether homogeneous, as small granules may 

1 Rovida, see J. Molesehott. Untersuchung. z. Naturlehre d. Menschen u. d. Thiere, 
1867, vol. xi., I. p. 132. 



MICROSCOPICAL EXAMINATION OF THE URINE. 527 

almost always be detected imbedded in or adhering to the matrix. 
As these granules occur in greater or less numbers, hyaline caste 

arc spoken of as being finely granular (Fig. 120), coarsely granular, 




>-* 



Hyaline tube-casts. 



finely dotted, etc. Should true morphological elements be detected, 
the casts are termed blood-casts, epithelial casts (Fig. 121), or pus- 
casts (Fig. 122). It would be better, however, to add the term 
hyaline in every instance, so as to distinguish them from pseudo- 
cysts, which consist of these elements entirely, and lack a uniform 



Fig. 120. 




Granular tube-casts. 



matrix. It would thus be proper to speak of hyaline epithelial casts, 
hyaline blood-casts, etc., and to apply "the collective term — compound 
hyaline casts — to these various sub varieties. 



■:_- 



_____ _._ _ - - 



:_: 
_- 



Lements it 

v : : : _ _ . 



F::- :_: 




also the end of the east will be seen to be more or less cKstinetlT 
hyaline. In others, again, a hyaline zone may be observed along 

:_t _:i-_s .: : :-___r*;_I .__/:::-•:- :____ ._•.:•; _t •_■.-__. :_i? ;:•_::__ :_t- 
quently seen in specimens which are very broad and long. Should 
doubt arise, however, a drop of acetic acid is added to a drop of 
the sedinient on the slide ; the acid dissolves the hyaline ma: 

:_-_ :_*_*: _::- . : : _-~7___-._ ;:._•_ --.- : :_■__-. :._•.! :__ __:rr-r___.I ._:■_::..?> 
between a pseudocast and a compound hyaliiH -: - thus readily 
r>_ r. _i_i-. I. 

Fk_1__ 






The length of hyaline casts varies greatly. It may scarcely 
exceed the breadth, on the one hand, while on the other, although 
rarely, the cast may traverse the entire microscopical field. In 
breadth they vary between 0.01 and 0.05 mm. As a rule, the 
breadth of a cast is uniform throughout its entire length, but speci- 



MICROSCOPICAL EXAMINATION OF THE URINE. 



529 



mens are not infrequently observed in which one end tapers con- 
siderably and presents a spirally twisted appearance. This may be 
so marked that the entire cast appears transversely striated. It 
is generally supposed that this results from the adhesion of one end 
of the casl to the walls of a tubule, the lumen of which it does not 
fill, SO that the tree end becomes twisted in the downward course. 
A dichotomous branching of one end is also at times seen in very 
broad hyaline specimens. 

•• Fatty globules are found upon the surface of granular casts 
(Fig. 123), but they also form by themselves short, strongly refrac- 
tive easts, which are often beset all over with needles of fatty crys- 
tals. These, however, are not composed exclusively of fat, but 
probably to some extent of lime and magnesium salts of the higher 

Fig. 123. 




a, Fatty casts, b and c, Blood-casts, d, Free fatty molecules. (Roberts.) 

fatty acids and allied compounds, for they are not all soluble in 
ether. They have their origin doubtless in fatty degeneration of 
the renal epithelium " (v. Jaksch). 

Granules of melanin, indigo, and altered blood-pigment may at 
times be observed in casts. Riedel regards the occurrence of dark- 
brown casts as pathognomonic of fractures. 

2. The waxy casts (Fig. 124) may be divided into two groups — 
true waxy casts and amyloid easts ; but as the latter are not neces- 
sarily indicative of the existence of amyloid degeneration of the kid- 
neys, such a classification is at the present time at least of only 
theoretical interest. They are readily distinguished from the hyaline 
easts by the characteristics mentioned above — L c, their higher 
degree of refraction, their yellow or yellowish-gray color, and the fad 
34 



530 



THE URINE. 



Fig. 121. 



that they are either not attacked at all by acetic acid or only very 
gradually. As a rule, only -mall fragments are found, but these are 
broader and more compact than the largest hyaline casts. Waxy casts 
may also contain cellular elements, crystals, and amorphous mineral 
matter ; but, as a rule, such compound casts are not so commonly 
observed as are those of the hyaline variety. From the latter they 
differ furthermore in frequently presenting a cloudy appearance, 
which in some cases is undoubtedly due to the presence of innumer- 
able bacteria, and it has been suggested 
that these may be directly concerned in 
their production. 

As has just been stated, some waxy 
casts give the amyloid reaction — i. e. } they 
assume a mahogany color when treated with 
a dilute solution of iodo-potassic iodide, 
which changes to a dirty violet upon the ad- 
dition of dilute sulphuric acid. It should be 
remembered, however, that this reaction in 
casts does not necessarily indicate the exist- 
ence of amyloid disease of the kidneys, as 
the reaction may be absent on the one hand 
in this condition, and present on the other 
where amyloid degeneration does not ex- 
ist. This curious phenomenon is usually 
explained by assuming that such casts 
have remained in the uriniferous tubules 
for a long time, and have there undergone 
certain chemical changes analogous to the 
so-called " amyloid metamorphosis " of 
old precipitates of fibrin, and it is indeed 
possible that waxy casts are originally 
hyaline. Frerichs has pointed out that 
fibrin which has remained in the uriniferous 
tubules for a long time becomes denser and 
yellowish in appearance, which would explain the fact that these 
casts are only with difficulty attacked by acetic acid. 1 

Before leaving this subject it should be stated that " cast-like " 
formations consisting entirely of amorphous urates are not infre- 
quently encountered in urines, and according to Leube they may be 
obtained from any urine if it is concentrated in a vacuum at a tem- 
perature of 37 : to 39° C. 2 Student- frequently regard such forma- 
tions as coarsely granular casts, an error which may be guarded against 
if the characteristics of hyaline casts set forth above are borne in mind. 
Bacteria (in cases of infectious pyelonephritis), haematoidin, and 

1 Eovida. loc. cit. Kobler. Wien. klin. Wocli., 1S90. vol. iii. pp. 531. 557, o74. 376. 

2 Leube, Zeit. f. klin. Med.. 1887, vol. xiii. 





Different forms of waxy 
asts: a. With a coating of 
urates, b. Waxy cast covered 
with crystals of calcium, oxal- 
ate, c, Fragments of waxy 
aste v. Jaksch.) 



MICROSCOPICAL EXAMINATION OF THE URINE. 531 

granular detritus frequently occur grouped in a cast-like manner; 
their nature is readily ascertained, as in the case of the so-called 
urate casts just described. 1 

Pseudocasts, consisting of epithelial cells or blood-corpuscles and 
fibrin, are not often found in urinary sediments. The epithelial 
pseudocasts are probably seen only in eases of desquamative nephritis, 
and, unlike true easts, are hollow, the epithelium of the uriniferous 
tubules being thrown off en masse. Blood-casts (Fig. 123) consist 
of fibrin, within the meshes of which red corpuscles arc generally 
found ; these either present a normal appearance or occur as mere 
shadows, owing to the fact that their haemoglobin has been dissolved. 
They arc seen whenever extensive hemorrhage has taken place in the 
renal parenchyma, and are far more frequently observed than the 
epithelial pseudocasts. Hyaline casts are probably always met with 
in urinary sediments in which pseudocasts are found, and may be 
readily distinguished from the latter even when beset with numerous 
epithelial cells or red corpuscles (see above). 

Cylinduoids (Fig. 125) resemble hyaline tube-casts somewhat in 
general appearance, but differ from them in being much larger and 
band-like. Like true casts, they have a uniform breadth, and are 
often beset with crystals and cellular elements, such as leucocytes, 
red corpuscles, and epithelial cells. They are readily dissolved by 
acetic acid, thus differing from the mucous cylinders or pseudo- 
cylinders (Fig. 126) which maybe observed in any urine containing 
mucus; the latter probably never contain morphological or mineral 
constituents, and are never of uniform breadth throughout their 
length. The cylindroids proper are undoubtedly of renal origin 
and closely related to true casts; formations are indeed not infre- 
quently >cvn in which a tube-cast terminates in a cylindroid at one 
or both ends (see Fig. 119). 2 

Formation of Tube-casts. — Several hypotheses have been advanced 
to explain the formation of tube-casts — reference is here had only to 
true casts, and not to pseudocasts, the origin of which is sufficiently 
obvious — and until recently it was quite generally accepted that they 
consist of coagulated albumin which has transuded into the tubules. 
According to this view, a cylindruria would always be indicative of 
the existence of albuminuria. In Xeubauer and Vogel's Urinary 
Analysis (ninth edition) it is stated that "as to the significance 
of tube-casts, it must be remembered that these, according 1<» <»nr 
present knowledge, consist of albumin, which coagulates under the 
influence of the acid reaction of the urine, in the renal paren- 
chyma, in a peculiar hyaline manner. They represent merely a 

1 Martini, Ar.li. f. klin. Chir., 1884, vol. xvi. p. 157. v. Jaksch, Deutech. med. 
Woch., 1888, vol. xiii. X<>s. 40and II. 

3 Bizzozero, loc. eit. Thomas. Arch. f. Heilk., W<>. vol. si. p. 130. Pollaku. 

T6rok, Arch. f. exper. Path. u. Phannakol.. 1-.--. vol. xxv. p. -7. 



532 



THE URINE. 



solidified portion of the albumin held in solution by the urine ; their 
elimination essentially indicates the existence of an albuminuria." 
More recently, however, it has been suggested, that tube-casts are 
the product of a faulty metamorphosis^ or of inflammatory irrita- 
tion of the renal epithelium, and that a secretion from these cells or 



Fig. 12-5. 




^<3/ 



a and b, Cylindroids from the urine in 
congested kidney, v. Jaksch.) 



Fig. 126. 



/ A 



Mucous cylinders. 



a disintegration of their protoplasm occurs, which results in the 
formation of cylindroids or true casts. 1 

Clinical Significance of Tube-casts. — Formerly the occurrence of 
tube-casts in urine was held to indicate the existence of nephritis. 

1 See also Rindfleisch. Lehrbuch d. path. Gewebelehre, Leipzig, 1875, p. 433. 
Langhans. Virchow's Arehiv. 1ST9. vol. lxxvi. p. 85. Eovida. loc. cit. Kobler. loc. 
cit. Ribbert. Centralbl. f. d. med. Wiss., 1880, vol. six. p. 305. 



MICROSCOPICAL EXAMINATION OF THE UBINR 533 

This view has been abandoned, however, for the same reasons which 
led to the rejection of the theory that albuminuria invariably indi- 
cates Bright^ disease (see above). 

The statement is frequently made in text-books thai tube-casts 
may occur in the urine of perfectly healthy individuals, following 
severe muscular exercise, cold baths, etc. — in short, all stimuli which 
may cause the appearance of albumin in apparently normal individ- 
uals. It has been indicated elsewhere (see Functional Albuminuria), 
however, that such stimuli cannot be regarded as "physiological" 
in every instance, and the presence of tube-casts in the urine similarly 
should be regardedas a pathological event} 

It is not necessary in this connection to enumerate the various 
diseases in which eylindruria is observed, as they are the same as 
those which give rise to albuminuria; and just as a nephrangiogenic 
albuminuria is more frequently observed than a nephriMdogenic albu- 
minuria, so also is the presence of tube-casts in the urine more fre- 
quently due to circulatory disturbances in the kidneys than to true 
nephritis. In every case in which tube-casts occur in the urine it 
may be assumed that the accompanying albuminuria is, to a certain 
extent at least, of renal origin. 

While the existence of eylindruria is not necessarily associated 
with definite pathological alterations of the renal parenchyma, this 
statement should be restricted to the occurrence of purely hyaline 
casts, and their presence in only small numbers. A few renal epi- 
thelial cells may be found at the same time, occurring either free in 
the urine or adhering to the casts, but never presenting an atrophic 
or otherwise altered appearance in the absence of definite renal lesions. 
The presence of compound hyaline and coarsely granular casts, as 
well as of waxy and amyloid easts, on the other hand, may probably 
always be regarded as indicating definite changes in structure, so that, 
so far as the diagnosis of nephritis is concerned, a microscopical 
examination of the urine will furnish information of more value 
than the simple demonstration of albumin. 

Hyaline easts are those most frequently seen, — reference is here 
had only to the purely hyaline or, at least, but faintly granular 
form, — and are found in all conditions in which albuminuria occur-. 
When present in only small numbers, and particularly when occur- 
ring but temporarily in the urine, it may be assumed, in the absence 
of other symptoms pointing to renal disease, that we are dealing 
with a mild circulatory disturbance of the kidney-. Renal epithelial 
cells are absent, or present, in only small numbers, 'flic albumin- 
uria at the same time is trifling. If. however, hyaline casts are 
continuously present in large numbers, and if the amount of albumin 
exceeds a trace, the existence of a nephritis may usually be inferred. 

1 Xothnagel. Deutsch. Arch. f. klin. Med., 1-71. vol.xii.p 326. Bnrkhart. Die 
Harucylinder, 1884. Fischel, Prag. Viertcljahrschr., 1-7- \<>1. <\xxix. p. 27. 



534 THE URINE. 

In such cases granular casts and compound hyaline casts, particu- 
larly the former, will be found if the nephritis is chronic, while in 
the acute form the hyaline type prevails. Should blood-casts be 
present at the same time, the probabilities are that we are dealing 
with an acute nephritis or an acute exacerbation of a chronic process ; 
in the latter case coarsely granular casts will also be present in large 
numbers. 

Waxy casts always indicate a chronic or, at least, a subacute 
process. The fatty casts described by Knoll and v. Jaksch " are 
most commonly associated with subacute or chronic inflammations 
of the kidney of protracted course, with a tendency to fatty degen- 
eration of the renal tissue. Post-mortem examination has shown 
that they form most frequently in cases of large white kidney. In 
some cases in which they were present, however, the organ was 
found to be more or less contracted ; but when this was so, it was 
invariably far advanced in fatty degeneration." 

It has been stated that from a careful examination of the renal 
epithelial cells it is often possible to determine whether an inflamma- 
tory process affecting the kidneys is at the same time complicated 
with degenerative changes. As a matter of fact, the cells found on 
the tube-casts under such conditions no longer present a normal 
appearance, but are shrunken and atrophied, and in cases of fatty 
degeneration studded with fatty granules. Epithelial casts, in the 
absence of distinct changes affecting the renal parenchyma, are prob- 
ably never seen. 

The occurrence of pus-casts presupposes the existence of suppura- 
tive inflammation in the kidneys, while the presence of only a small 
number of leucocytes on hyaline casts may be observed in the ordi- 
nary forms of nephritis, and particularly in the acute form. 

The pathological significance of the so-called amyloid casts and 
pseudocasts has already been considered. 

Cylindroids are present whenever hyaline casts are seen, and have 
essentially the same import. They are said to occur most frequently 
in the urine of children. 

So far as the constancy with which tube-casts occur in the urine 
in nephritis is concerned, it is well known that in the chronic inter- 
stitial form of the disease they, as well as the albumin, are frequently 
absent for a long time, so that it may only be possible to make the 
diagnosis from the clinical history and the physical signs. It is a 
well-known fact, moreover, that pathological alterations of the kid- 
neys, particularly in men past middle age, are observed again and 
again in the post-mortem room, where a previous examination of the 
urine showed no evidence of the existence of renal disease. In the 
acute and subacute forms of nephritis, as well as in the ordinary 
parenchymatous form, tube-casts are probably always found, and it 
would further appear that acute circulatory disturbances affecting 



MICROSCOPICAL EXAMINATION OF THE URINE. 



535 



the renal parenchyma quite constantly lend, not only to albuminuria, 
but also to cylindruria. 

Spermatozoa. — Spermatozoa, lorn description of which the reader 
is referred to the chapter on the Semen, arc frequently observed in 
the urine of healthy adults, and are quite constantly met with in the 
first urine passed after coitus or nocturnal emissions, when their 
presence is, of course, of no significance (Fig. 127). Such urine- 
are always cloudy, but it is impossible to recognize the source of the 
turbidity by simple inspection. 

A sediment composed of phosphates is popularly often regarded 
as due to semen, and no doubt every physician has seen patients, 
— usually sexual neurasthenics, — who were greatly alarmed at find- 
ing a white deposit in the chamber, and who imagined themselves 

Fig. 127. 




Human spermatozoa. 



" sufferers from loss of manhood." The microscope is necessary in 
every case to determine the presence of spermatozoa. 

In female- Bemen may be found in the urine whenever the external 
genitals have been polluted during or after coitus, as well as in the 
exceptional cases in which connection has been effected by the urethra. 
From a medico-legal standpoint the discovery of spermatozoa in the 
urine of women may be of the greatest importance, but otherwise it 
is without significance. 

In a few instances it is stated that trichomonads have been mis- 
taken for spermatozoa. I am convinced, however, that such an 
error can only occur if the observer is totally unacquainted with the 
subject under consideration. 

In pathological conditions spermatozoa are not infrequently found 
in the urine. In cases of obstinate constipation, owing to pressure 



536 THE URINE. 

of hard scybalous masses upon the seminal vesicles, a partial evacu- 
ation of semen may occur, which may or may not be accompanied 
by sexual excitement. Horowitz has pointed out that a discharge 
of semen may be noted in cases of peri-urethral abscess with per- 
foration into the ejaculatory ducts, giving rise to spermato-cystitis, 
the condition being due to a tight stricture of the urethra with 
dilatation beyond the constricted portion. I have observed a case 
of cystitis in which spermatozoa could almost always be detected 
in the urine. An operation revealed a tight stricture of the urethra 
and a sacculated bladder ; the constant passage of semen was 
apparently owing to the irritating action of the ammoniacal urine. 
It should be noted that in this case, as well as in those in which 
semen is frequently passed during the act of defecation in the absence 
of sexual excitement, no deleterious effects referable to such loss were 
noted. In the urine voided during and after epileptic and, more 
rarely, hystero-epileptic seizures spermatozoa may be found. Such 
an event is undoubtedly due to muscular spasm, and is identical in 
origin with the emission of semen observed so frequently in the 
death agony, and especially during strangulation. 

In certain spinal diseases semen may be found in the urine, and 
Fiirbringer relates a case in which, following fracture and dislocation 
of the vertebral column, with partial destruction of the middle dorsal 
cord, spermatorrhoea associated with partial erection occurred thirty 
hours later, and continued until death, which took place after three 
days. 

More important is the loss of semen noted in cases of true sperma- 
torrhoea due to venereal excesses or masturbation, when spermatozoa 
may be found almost constantly, and the diagnosis indeed will often 
be dependent upon such an observation. 

So far as the question of sterility in the male is concerned, reliance 
should not be placed upon an examination of the urine, but the semen 
should be obtained as soon as possible after ejaculation, and exam- 
ined as indicated elsewhere (see page 566). 

Parasites. — Vegetable Parasites. — It has been shown by numerous 
investigations that bacteria are always present both in the male and 
female urethra, and that they may at times gain entrance to the 
bladder. The weight of evidence, however, is in favor of the view 
that the urine intra vesicam is under normal conditions free from 
micro-organisms, and that any bacteria which may have found their 
way into the bladder are rapidly killed in healthy individuals. In 
every urine, on the other hand, that has been exposed to the air, 
bacteria are always present. ^Whenever, then, it is desired to deter- 
mine whether or not the urine of the bladder contains micro-organ- 
isms, every precaution should be taken to guard against accidental 
contamination. To this end, the following method should be em- 
ployed : if the patient is a male, he is instructed to hold his urine 



MICROSCOPICAL EXAMINATION OF THE URINE, 537 

until a fairly large amount lias accumulated. The glans is then 
thoroughly washed with soap and water, and further cleansed with 
cotton -naked in mercuric chloride solution (1 : 1000). The fossa 
naviculars is also thoroughly cleansed with the same solution. The 
urine is then voided under as great pressure as possible. The firsi 
portion (about 100 e.c) is thrown away, and the second received in 
8 sterilized vessel, when cultures should be made at once, agar or 
gelatin plates being inoculated with 1 or 2 c.c. of the urine. Id 
the female the vulva is cleansed with soap and water, and the urethral 
aperture disinfected with bichloride solution. After then washing 
with sterilized water and drying with sterilized cotton the urine is 
evacuated through a sterilized metallic or glass catheter, and received 
in a sterilized vessel. BroAvn describes the method which is in use 
in Dr. Kelly's department at the Johns Hopkins Hospital as follows : 
the external urethral orifice being carefully cleansed with mercuric 
chloride solution, followed by sterile water, a sterilized glass catheter, 
whose external end is covered by a sterile rubber cuff, extending 
several centimeters beyond the end of the catheter, is introduced, 
the lingers of the operator being allowed to touch only the distal end 
of the rubber cuff. The urine is allowed to flow for a short time, 
when the rubber cuff is pulled off by traction on its distal end. 
A -mall amount of urine is then collected in a sterile test-tube, 
and the cotton plug immediately inserted. Brown states that an 
extended series of experiments with normal urines 
has shown that this method is absolutely reliable. 1 Fj g- I 28 - 

Of the bacteria which may be found in every 
urine that has been exposed to the air, the Micro- 
coccus urece is of special interest, as ammo- 
niacal fermentation is largely due to its presence. 
When fermentation has commenced, it is readily 
recognized, occurring in almost pure culture upon 
the surface of the urine, mostly in the form of 
characteristic chains (Fig. 128). The individual coccus is colorless 
and quite large, so that it may be mistaken by beginners for a blood- 
shadow. 

It is a common error to infer from the occurrence of ammoniacal 
decomposition very soon after micturition that this process has already 
begun in the bladder. It should be remembered that urine may un- 
dergo fermentation, particularly in warm weather, shortly after having 
been voided, and especially if the vessel employed is not perfectly 
clean and the urine has been exposed to .the air. The diagnosis of 
ammoniacal fermentation in the bladder should hence only be made 
when the presence of ammonia can be demonstrated in the urine 
immediately upon being voided. 

Under pathological conditions various pathogenic bacteria may be 

1 T. R. Brown, loc. cit. 



.Z "' -v <• 

- — \ '-v -*y 




3' 




Micrococcus 


urea' 



538 THE UBINK 

found in the urine. Their presence usually indicate- the existence 
of definite changes in the renal parenchyma, although these changes 
are not necessarily of an inflammatory character. Pyogenic cocci 
are especially prone to settle in the kidneys, and there give rise to 
focal inflammation- ; but even in the absence of such lesions they are 
frequently found in the urine. In all forms of infectious nephritis 
an abundant elimination of bacteria may generally be observed, v. 
Jaksch states that in erysipelas the bacteriuria and nephritis dis- 
appear, together with the cessation of the disease, and in various 
suppurative processes taking place in the body the specific bacteria 
disappear from the urine within twenty-four to forty-eight hours 
after evacuation of the pus. 

Most interesting observations on the occurrence of bacteria in the 
urine of nephritic patients have been reported by Engel. Thirty- 
one cases were examined. In sixteen the Staphylococcus albus and 
aureus were found, in eight pyogenic streptococci, in four the tubercle 
bacillus, in five the Bacillus coli communis, and in one the typhoid 
bacillus, while negative results were obtained in only two instances. 
In the same series Engel also found a pyogenic coccus in seventeen 
cases. This coccus was larger than the known forms : it could be 
stained according to Gram's method, and did not liquefy gelatin. 
Intravenous injections of large numbers of the organism caused 
nephritis in rabbits. 

In pneumonia and pneumococcus infections in general the corre- 
sponding diplococcus may be found, and in erysipelas and strepto- 
coccus infections streptococci. Very common is the presence of 
the Bacillus coli communis in cases of pyelonephritis : it is usually 
found in pure culture, but is at times associated with the Staphy- 
lococcus aureus and the Proteus vulgaris. In some instances the 
latter organism has also been met with in pure culture. 

Of great interest is the frequent occurrence of the typhoid bacillus 
in the urine of typhoid fever patients. Bouchard 1 in 1881 drew 
attention to the elimination of the bacillus through this channel, and 
stated that he was able to demonstrate its presence in 50 per cent. 
of his typhoid fever cases. Other observers were less successful, but 
with improving technique and more general investigation a larger 
number of positive results is being obtained every year. 2 At the 
present time it may be said that the typhoid bacillus can be found in 
the urine of from 20 to 30 per cent, of all typhoid fever patients. 
The organism usually appear- in the second or *third week of the 
disease, and may persist foi months and even vears. ^Vhen pre-ent 
it usually occurs in pure culture, and often the bacilli are so numerous 
as to render cloudy a freshly voided specimen of urine. Symptoms 

Bouchard. Rev. de Med.. 1881, p. 671. 

2 For an account of the literature, see T. R. Brown. ■• Ostitis due to the Typhoid 
Bacillus." etc.. Med. Record, March 10. 1900. 



MICROSCOPICAL EXAMINATION OF THE URINE. 539 

of cystitis and marked renal involvement often occur, but in a con- 
siderable Dumber of cases there are do indications of local disease. 
The elimination of the organism in the urine is of no prognostic 
significance, but is important from the standpoint of prophylaxis. 

Of special interest is the fact that the organism maybe found in the 
urine although the patient is not the subject of typhoid fever at the 
time. Brown 1 thus reports the case of a woman in whom a cystitis 
developed on the ninth day following an abdominal operation, and 
in whom it was thought that the typhoid bacillus was accidentally 
introduced by the catheter. The patient had had typhoid fever 
thirty-five year- previously. Young 2 gives the history of a patient 
in whom cystitis developed during an attack of typhoid fever, owing 
to infection with the typhoid bacillus. The organism could still be 
demonstrated in the urine after seven years. A double infection 
with the gouococcus subsequently occurred, and four months later 
typhoid bacilli and gonococci were both present in considerable 
numbers. Cystoscopic examination showed a chronic ulcerative 
cystitis. Two additional cases of chronic cystitis due to the typhoid 
bacillus are reported. 

The bacillus may be isolated and identified according to the usual 
method (see page 254). 

Very important further is the fact that in tubercular disease of the 
urinary organs tubercle bacilli may be found in the urine. The 
search for them, however, is always tedious and frequently fruitless. 
In suspected cases it is best to centrifugate the urine, and to spread 
the sediment upon slides or cover-glasses. The preparations are then 
fixed by heat, and are best stained with Pappenheinr's reagent (see 
page 285). Grethe' 's method ', which was formerly used to differentiate 
the two, is less reliable. With this method the specimens are stained 
with a concentrated alcoholic solution of fuchsin, the staining fluid 
being brought to the boiling-point on the slide. They are then washed 
in water and counterstained with a concentrated alcoholic solution of 
methylene-blue without the application of heat. The excess of stain 
is washed off, when the preparations are dia'ed with filter-paper and 
examined as usual. As with Pappenheim's method, the tubercle 
bacilli are colored red, while the other morphological elements which 
may be present, including the smegma bacillus, are stained bine. 
The usual methods of staining arc not admissible, as the smegma 
bacillus, which may also be present in the urine, is likewise stained, 
and may readily be mistaken for the tubercle bacillus. 

If, in suspected cases, notwithstanding repeated examination and 
the preparation of numerous specimens, tubercle bacilli are not found, 
it is best to inject a lew drops of the sediment into the anterior 

1 Loc. cit 

2 H. H. Young, '•Chronic Cystitis due to the Bacillus Typhosus," Maryland Med. 
Jour., Nov., 1901. p. t",(i. 



540 THE URINE. 

chamber of the eye of a rabbit, and to watch for the development 
of miliary tubercles in the iris. 

The number of bacilli which may be found in the urine in tuber- 
cular disease of the urinary organs is extremely variable. Fre- 
quently none at all are found, notwithstanding careful search ; in 
other cases they are present in small numbers ; while in still others 
they are extremely numerous, and are often bunched to form par- 
ticles visible to the naked eye. 

Isolated tubercle bacilli have also been found in the urine in cases 
of acute miliary tuberculosis, in the absence of renal changes ; such 
observations, however, are rare. 

The goaococcus of Neisser 1 is rarely found free in the urine, but 
for sake of convenience is described at this place. The organism 
(Plate XIX.) occurs in the form of small oval or round granules, 
usually grouped in twos and fours, resembling a German biscuit or 
the figure 8. As a rule, it is found enclosed within pus-corpuscles 
and epithelial cells ; but it may also occur free in the pus obtained 
from the urethra, in the vaginal discharge, and more rarely in uri- 
nary sediments, as in cases of complicating prostatitis, peri-urethritis, 
etc. In cover-glass preparations account should be taken only of 
those organisms which are enclosed within cellular elements, as these 
alone may be regarded as characteristic. To this end, a drop of the 
discharge is spread in a thin layer upon a slide or cover-glass, dried 
in the air, and fixed by passing three or four times through the 
flame of a Bunsen burner. The specimens may then be stained 
with any one of the basic anilin dyes. In my laboratory the eosinate 
of methylene-blue is almost exclusively used for this purpose (see 
page 9 9 J. The organisms are thus colored blue, while the granules 
of the eosinophilic leucocytes, which are commonly present at the 
same time, appear a bright red or a brownish red. After five 
minutes the excess of stain is washed off, the preparations are rinsed 
in water, dried with filter-paper, and examined with a high power. 

Of special interest is the observation of Unna and Plato, 2 that the 
gonococcus can be stained in the living leucocyte with Ehrlich's 
neutral red. The method employed is simple. A small drop of 
the fresh pus is mixed with an ose of a dilute solution of neutral 
red in normal salt solution (1 c.c. of a saturated aqueous solution 
to 100 c.c), and examined either as hanging drop or mounted on 
a slide as usual. Thus prepared, a certain number of the intracel- 
lular gonococci are stained a deep red, while others are not stained ; 
and it may be observed on warming the slide, so as to elicit amoeboid 
movements, that some of the gonococci which are stained so long 
as they remaiu within the granular portion of the leucocytes, are 
gradually decolorized when they come to lie in the homogeneous 

1 Xeisser, Centralbl. f. d. med. Wis?.. 1879. vol. xvii. p. 497. 

2 J. Plato, " Ueber Gonokokkenfarbuiig mit Xeutralrotb," etc., Berlin, klin. Wocb., 
1899, p. 1085. 



PLATE XIX 



**,-. 



* *» «a 



•v..;- 


■ v. 




v. ja 






" fe| "- *" 






V" A; * «- 






■*•'. 








.. SCHMIDT, 


FEC 



Urethral Discharge from a Case of Gonorrhoea, showing Gonocoeei Enclosed 
Pus Corpuscles, and Lying Free in the Discharge. Stained with 



— ' — J o - - —"— — — -— — ••» — • 

Methylene Blue. (Personal Observation.) 



MICROSCOPICAL EXAMINATION OF THE URINE. 541 

ectosarc, and arc colored again on returning to the granular pro- 
toplasm. Plato states that be lias examined numerous other intra- 
cellular organisms, including pseudogonococci, bul that he has never 
observed as rapid and intense staining as with the true gonococci. 
He therefore suggests that with neutral red it may he possible to 
differentiate the gonococcus from similar organisms. Extra-cellular 
gonococci, as well as numerous other bacteria, are not stained, even 
after an exposure of several days. 

When no discharge can be obtained from the urethra, or an ex- 
amination of such discharge is negative, positive results may at times 
still be obtained if some of the gonorrheal threads are examined 
which may be found floating in the urine. In these the organisms 
can occasionally be demonstrated after months and even years have 
elapsed since the primary infection. 1 

In doubtful cases, and especially in women and children, cultures 
should be made, as the organisms may be confounded with pseudo- 
gonococci, which are frequently present both in the diseased and 
normal urethra of males and females. The organism grows best on 
a mixture of human blood-serum and nutrient agar (1 : 2 or 3 parts). 
The surface colonies are pale, grayish, translucent, and finely granu- 
lar, with finely notched borders. In bouillon and blood -serum 
mixed it forms a membrane, while the fluid remains clear. On agar 
the organism does not grow. Like the pseudogonococci, the gono- 
cocci are decolorized by Gram's method. 

In cases of cystitis a great variety of micro-organisms has been 
met with in the urine. Among the more important may be men- 
tioned the Staphylococcus aureus, albus, and citreus, streptococci, 
the Bacillus coli communis, the Bacillus pyocyaneus, the Bacillus 
typhosus, the Proteus vulgaris, etc. In many eases of cystitis 
organisms are found, moreover, w r hich are apparently non-patho- 
genic, and are capable of causing the formation of hydrogen sul- 
phide from certain sulphur bodies of the urine (see Hydrothionuria). 

Actinomyces kernels may be observed in the urine when the 
disease in question has attacked the genito-urinary tract or when 
the organism has found its way into the urine from other organs. 

In conclusion, reference should be made to the occasional occur- 
rence of a form of bacteriuria which is not associated with any 
pathological process, and has hence been termed idiopathic bacteriuria. 
Of its causation and significance nothing is known, but it is pos- 
sible that in these cases a few bacteria enter the bladder either 
through-the anterior rectal wall or are eliminated through the kid- 
neys from the blood-current. Finding a suitable medium for their 
growth in the urine, they here multiply and may thus be constantly 
present. Of late, the Bacillus lactis aerogenes has been found in 

1 E. R. Owing:?, "The Infectiousness of Chronic Urethritis,'" Bull. Johns Hopkins 
Hosp., 1897, p. 210. 



542 THE URINE. 

such a case. The diagnosis " idiopathic bacteriuria " should, of 
course, only be made if every possible source of contamination of 
the urine can be definitely excluded. 1 

Urines containing bacteria in large numbers are always cloudy, 
and usually present an acid reaction when voided unless cystitis 
exists at the same time. Attention is directed to their presence by 
the fact that such specimens cannot be cleared by simple filtration. 

Yeast-cells in large numbers are usually only seen in urines con- 
taining sugar. Whenever a chemical examination has not been made 
their demonstration will be of importance, as suggesting the pos- 
sible existence of glucosuria. 

Moulds are usually seen in old diabetic urines after alcoholic fer- 
mentation has taken place, but they may also occur, though far less 
frequently, upon the surface of putrid urines that have contained 
no sugar. 

The urinary sarcina which is at times met with is smaller than 
the sarcina of the gastric contents, but closely resembles it in appear- 
ance. It is of no clinical significance. 

Whenever a urine is to be examined bacteriologically, special pre- 
caution should be taken to guard against its accidental contamination. 
The safest procedure, of course, is to obtain the urine by suprapubic 
puncture. This is, however, only exceptionally necessary, and as a 
general rule the method of disinfection which I have described 
above (see page 537) will suffice. 

Animal Parasites. — The organism which Hassal saw io a urine 
that had been " freely exposed to the air " and was alkaline, and 
which he termed Bodo urinarius, was in all probability an infusorial 
monad and of no pathological significance. Salisbury was the first 
to point out that the Trichomonas vaginalis of Donne may at times 
occur in the bladder, but he gave no detailed account of his cases. 
K mistier, Marchand, Miura, and Dock subsequently reported cases in 
which flagellate protozoa were found, and modern research leaves no 
doubt that the organisms described by these observers are identical 
with the trichomonas of Donne. In Miura's case the habitat of the 
parasite was the urethra, and an examination of the patient's wife 
revealed the presence of similar organisms in the vagina; Kiinstler's 
case was one of pyelitis following cystotomy. Marchand' s patient 
had a fistula in the perineum following suppuration in the pelvis, of 
unknown origin ; cystitis did not exist. Dock's case was associated 
with hematuria. During the past few years I have seen the same 
organism in six cases, two of which occurred in the practice of Dr. 
W. M. Lewis, of Baltimore. Five were women, and I have no doubt 
that the parasite found its way into the bladder from the vagina, 

1 Roberts, " On Bacilluria," Trans. Internal Med. Cong., London, 1831. vol. ii. 
p. 157. Schottelius u. Reinhold. Centralbl. f. klin. Med., 1886, vol. viii. p. 635. Ross. 
Baurugarten's Jahresber., 1891, vol. vi. p. 360. 



MICROSCOPICAL EXAMINATION OF THE URINE 543 

where it could be demonstrated in two instances. Curiously enough, 
a history of hematuria was obtained Prom three of the six patients. 
In one ease the urine contained blood at the time of the examina- 
tion. Evidence of nephritis or well-marked cystitis did not exist. 
The number of the parasites was variable, and in four cases large. 1 

Balz observed numerous amoebae in the turbid urine of n girl the 
subject of phthisis, which he described as being of Larger size than 
the Amoeba coli. Ciliated infusoria have also been found in the 
urine in isolated cases. 

The ova of Distoma haematobium and the Filaria sanguinis 
hominis are at times found in the urine, their elimination being 
usually accompanied by hematuria and chyluria. Echinococcus 
booklets and fragments of cysts may also be found, and in rare in- 
stances ascarides find their way into the urinary passages when a 
fistulous opening exists between the rectum and the bladder. Both- 
riocephalus linguloides (Leuckart) was found in the urine in a case 



Fig. 1-29. 









A gonorrhccal thread. 

occurring in Eastern Asia. Eustrongylus gigas is likewise found 
very rarely. Moscato records one case in which chyluria existed :it 
the same time. In Dr. Clark's ease, which was recently reported 
in this country, the passage of the worm was accompanied by 
hematuria. 

Tumor-particles. — Tumor-particles are so rarely seen in the 
urine that a detailed account of their occurrence may be omitted, 
particularly as it is seldom possible to base the diagnosis of tumor 
upon the presence of fragments in the urine, the clinical history and 
the physical Bigns being usually sufficient to reach a satisfactory 
diagnosis. 

Foreign Bodies. — Of foreign bodies which may be found in the 
urine may be mentioned particles of fat, fibres of silk, linen, and 
wool, etc.'; in short, material the presence of which is owing to the 
use of unclean vessels for reception of the urine. Fecal matter may 

1 Dock. Am. Jour. Med. Sci.. Jan., 1896. 



514 THE URINE. 

be parsed by the urethra : such an occurrence, of course, always in- 
dicates the existence : an abnormal communication between the 
bowel and the urinary pa— ^ T -. Hair derived front a dermoid cyst 
may similarly be found. In hysteria foreign bodies of almost any 
kind, such as hair, teeth, nsh-bones. wood, etc.. and even snakes and 
frogs, may be shown the physician as having been passed in the urine. 
I had oc: don : examine grave] •■ passed " from time to time by 
a hysterical patient in large amounts. " every attack being accom- 
panied by agonizing pains shooting down into the lower abdomen"' ; 
the gravel upon examination proved to be mortar, obtained from the 
cellar of the patient's house 



CHAPTER VIII. 

TRANSUDATES AND EXUDATES. 

In health the so-called serous cavities of the body contain ver\ 
little fluid, and quantities sufficient for analytical purposes can nor- 
mally only be obtained from the pericardial sac. In pathological 
conditions, on the other hand, large accumulations of fluid may be 
observed, not only in the serous cavities, but also in the areolar con- 
nective tissue, beneath the skin, and beneath the muscles. When 
due to circulatory disturbances, a hydraemic condition of the blood, 
or an insufficient elimination of water through the kidneys, such 
accumulations of fluid are spoken of as transudate*, while the term 
exudates is applied to similar accumulations of inflammatory origin. 

Clinically, it is frequently difficult to distinguish between trans- 
udates and exudates, and large ovarian, pancreatic, and hydatid 
cysts, as well as cystic kidney-, may at times be mistaken for ascites. 
In such cases a careful chemical and microscopical examination of 
the fluid in question may be of decided value. Very frequently, 
moreover, it is possible only in this manner to determine the nature 
of the disease, and the free use of the trocar and the aspiraMng- 
needle in diagnosis cannot be too strongly advocated. 

TRANSUDATES. 

General Characteristics. 

Transudates are usually serous in character, when they present a 
light-straw color : at times, however, owing to admixture of blood, 
they have a reddish tinge, and are then said to be sanguineous ; in 
rare instances they are chylous. 

Specific Gravity. 

The specific gravity varies somewhat according to the origin of 
the fluid, but is usually lower than that of serous exudate- occurring 
in the same cavities — one of the most important points of difference 
between the two kinds of fluid. Thus, in acute pleurisy the specific 
gravity of the exudate is usually higher than 1.020 : and in chronic 
pleurisy, if an accumulation of pus exists at the same time, higher 
than 1.018, reaching even 1.0o«>. In transudates into the pleural 
cavity, on the other hand, referable to circulatory disturbances, for 

35 



■: ~ TRANSUDATES AXD EXUDa II > 

example, as in cases of hepatic cirrhosis or cardiac insufficiency, the 
figures obtained are usually lower than 1.015. Transudates of peri- 
toneal origin similarly present a specific gravity varying between 
1.005 and 1.015, while that of exudates frequently reaches 1.030. 

A - the chemical composition, in so far as the mineral constituents 
and extractives are concerned, is practically the same in both clas - e b 
of fluid, the difference in the specific gravity appears to be essen- 
tially due to the amount of albumin present, viz., senun-albumin and 
serum-globulin. It may be demonstrated, as a matter of fact, that 
exudates contain far more albomin than transudates, the amount 
varying between 4 and 6 per cent, in the former, as compared with 
1 and 2.5 per cent, in the latter. The largest amounts of albumin 
in transudates are found in those of pleural origin, while in oedema 
not more than 1 per cent* is usually present. 

In the table below, taken from Reuss, the relation between the 
percentage-amount of albumin and the corresponding specific gravity 
b shown. Reuss suggests the following formula for the purpose 
of determining from the specific gravity the amount of albumin in 
transudates and exudates : 

E=% S— 1000)— 24, 
in which E indicates the percentage-amount of albumin and 8 the 
specific gravity taken by means of an accurate urinometer. 



um 

1.009 0.6 

1.0HO ... 1.0 



1-019 43 

1.020 .4.7 

1.021 5.1 



l.'lll 1.022 5.5 

1.012 1.7 L023 5J8 

1.013 2.1 1.024 6.2 



1.014 2.5 

1.015 3 

1.016 3.2 

1.017 36 

1.018 4.0 



1.025 6.6 

1.026 7.0 

1.027 7.3 

1.028 



The following table shows the percentage-amount of albumin 
obtained by Runeberg in ascitic fluid under various pathological 

: niiT:: _« : 

- 1 ~ ..' :■ - :'.". - ". i:.^"- "i-t.-- : - ;-: : :~ -i.- 
etc., with amyloid degeneration 0.21 :.4l 

z : - : - - rtffr. ':'.- :: _r '::-.::: ::r:i *::« 
orsteoosts| 0.97 _ f.? 0.37 

'--_~ttI. --:: i; -::-> rf:'rri I : :- 
ganie heart-disease i) 1.67 230 0j84 

Carcinoma of the peritoneum (compli- 
cated with carcinoma of the stomach 1 3 51 5.42 i ~ 

■! '■.:■- -.': : r-r : ' r '.:.- t.t v.-t :-:n: .:'-■'. 
witA heart-disease 3.71 4.25 3.36 

The fact that transudates do not coagulate spontaneously in the 
absence of blood may further serve to distinguish them front exu- 



TRANSUDATES. 547 

dates, in which a coagulum i> frequently observed after standing 
for twenty-four hours. Not much reliance should be placed upon 
this point of difference, however, as exudates likewise do not always 
coagulate, and clotting of transudate- in the presence of blood may 
take place within the body. 

LiiT.i:vni:i:. Eteuss, Deutsch. Arch, f. klin. Med., vol. xxviii. p. .".IT. Rune- 
_ [bid., L884, vol. \\\i\. pp. 1 and 266; and Berlin, klin. Woch., 1897, No. •'!:;. 

Citron, [bid., 1897, p. 854 ; and Deutsch. Arch. f. klin. Med., vol. xlvi. Ranke, Mit- 

thi.il. a.d. mod. Klin. z. Wurzburg, L886, vol. ii. p. 189. 

Chemistry of Transudates. 

An idea of the chemical composition of the various forms of 
transudates may be formed from the following tables, taken from 
Hoppe-Seyler and Hammarsten, the figures corresponding to 1000 
parts by weight of fluid ; the specimens were taken from one 
individual : 

Pleura. Peritoneum. ^hVi'^t ' 

Water 957.59 967.68 982.17 

Solids 4-2.41 32.32 17.83 

Albumin 27.82 16.11 3.64 

Ethereal extract "] 5.27 0.50 

Alcoholic extract f 3.71 

Aqueous extract }■ 14.59 10 94 \ *'^ 

Inorganic salt- ' j 9.00 

Errors of analysis J [0.12 

Analysis of Hydrocele Fluid. 

Water 938.85 

Solids 61.15 

Fibrin (formed) 0.59 

Globulins 13.52 

Serum-albumin 35.94 

Ethereal extract 4.02 

Soluble salts - 

Insoluble salts 0.66 

Sodium chloride 6.19 

Sodium oxide 1.09 

Sugar and uric acid in small amount- are also, as a rule, found in 
transudates, and in one case of hepatic cirrhosis Moscatelli succeeded 
in demonstrating the presence of allantoin. v. Jaksch 9tates that he 
lias frequently been able to demonstrate the presence of urobilin in 
both transudates and serous exudate-, even though red blood-cor- 
pusclesand blood-coloring matter in solution were absent. Peptone 
i- never found ; and Paivkull states that nucleo-albumin is not 
present in transudates of non-inflammatory origin. 

Literature.— Moecatelli, /'it. f. physiol. Chem., L889, v«.l. xiii. p. 202. v. Jaksch, 
Zeit f. Ilcilk.. 1891, vol. xi. p. 140. Eichhorst, Zeit. f. klin. Med., 1881, voLiii. 
p. 537. 



548 TRANSUDATES AND EXUDATES. 

Microscopical Examination of Transudates. 

Upon microscopical examination only a few isolated leucocytes 
and endothelial cells derived from the serous surfaces and under- 
going fatty degeneration are usually seen. Mast-cells and eosinophilic 
leucocytes have been observed in the ascitic fluid in cases of myeloge- 
nous leukaemia. Charcot-Leyden crystals were present at the same 
time. In cases in which the transudates have been confined for a 
long time plates of cholesterin are frequently found. They are 
especially abundant in hydrocele fluid. 

EXUDATES. 

Exudates may be serous, serofibrinous, seropurulent, purulent, 
putrid, hemorrhagic, chylous or chyloid, terms which do not require 
further definition. 

The purulent, seropurulent, and putrid forms are manifestly of 
inflammatory origin ; while it may at times be difficult to decide the 
nature of serous, serofibrinous, and serosanguineous fluids. In such 
cases the points of difference already described between transudates 
and exudates should be borne in mind, and will, when taken in con- 
junction with the physical signs and the clinical history, generally 
lead to a correct diagnosis of the origin of the fluid. 

Serous Exudates. 

Serous exudates are clear, of a light-straw color, and present a 
specific gravity usually exceeding 1.008. On standing, a white, 
fibrinous coagulum is generally formed. Such exudates, as indi- 
cated, differ from the corresponding transudates in presenting a 
higher specific gravity, and in the fact that clotting in transudates is 
observed only in the presence of blood. Exudates, however, do not 
invariably coagulate, and hence too much importance should not be 
attached to this point (see also page 547). 

Upon microscopical examination some red corpuscles, which are 
probably referable to the puncture, polynuclear leucocytes, and endo- 
thelial cells undergoing fatty degeneration are found. 1 

Widal reports that in three cases of acute rheumatism he found 
polynuclear leucocytes in the serous exudate, while these were absent 
in traumatic cases of arthritis. He maintains that an examination 
of the cellular elements which may be found in pleural effusions 
may furnish valuable information from the standpoint of diagnosis, 
pathogenesis, and etiology. To this end, a few cubic centimeters of 
the fluid are withdrawn with a hypodermic syringe, defibrinated, and 
centrifugated. The residual material is then spread upon cover- 
glasses, fixed and stained with thionin, haeruatoxylin-eosin, Ehrlich's 

1 Bizzozero, loc. cit. 



EXUDATES. 54!) 

triacid stain, or with eosinate of methylene-blue, which 1 personally 
prefer. In idiopathic pleurisy small lymphocytes, together with 
a few isolated red corpuscles, are exclusively found. In the 
various tonus of tubercular pleurisy morphological elements are 
essentially absent ; only a few partially broken-down polynuclear 
leucocytes are seen. In a case of serofibrinous pleurisy refera- 
ble to streptococcus infection neutrophilic polynuclear leucocytes 
were found. Especially noteworthy are the findings in pneumo- 
coccus cases : besides red corpuscles and a few leucocytes, numer- 
ous polynuclear cells are seen, as also large numbers of mono- 
nuclear cells of endothelial origin, some of which may be very large 
and enclose polynuclear leucocytes in their interior. In cases of 
traumatic and aseptic pleurisy, in association with diseases of the 
heart and the kidneys, on the other hand, large endothelial cells from 
the surface of the serous coat, occurring either singly or in groups 
of two, or three, or four, are especially characteristic. 1 

Hemorrhagic Exudates. 

Hemorrhagic exudates are essentially serofibrinous in character, 
the color depending upon the amount of blood-pigment present. 
Microscopical examination reveals the presence of a large number 
of red corpuscles, polynuclear leucocytes, and endothelial cells. 
Cholesterin-crvstals may also at times be seen, though rarely in large 
numbers. When numerous, attention is readily drawn to them, dur- 
ing the macroscopical examination of the fluid, by the peculiar glis- 
tening appearance of its surface. 

Tuberculosis. — As hemorrhagic exudates are most commonly 
observed in cases of tuberculosis and of carcinoma of the lungs and 
pleura, the specimen should be carefully examined for tubercle bacilli 
and cancer-cells. In every case it will be best to subject portions of 
the fluid to centrifugation and to examine the sediment thus obtained. 
I'-ually tubercle bacilli are not found, even when tuberculosis of the 
pleura exists. If in such cases culture-experiments likewise prove 
negative and cancer-cells are not found, the diagnosis of probable 
tuberculosis will nevertheless be warrantable. 

Cancer. — The diagnosis of cancer should be based upon the 
demonstration of cancer-cells in the fluid. The physician, however, 
i> warned not to mistake endothelial cells for cancer-cells. The 
diagnosis should hence only be made when epithelial cells of vari- 
able form, measuring at times 120 fi in diameter, are found in large 
numbers, especially when arranged in groups, unless, indeed, can- 
cerous nodules presenting the characteristic alveolar structure are 
at once found. 

1 Wirtal and Ravaut, "Cystodiagnostic dea epanchementa st'ro-fibrineux dc la 
pl&vre," Trans. XIII. Internat. Med. Congress, Paris. 1 !)<><>. 



550 TRANSUDATES AND EXUDATES. 

Rieder has lately called attention to the occurrence of cells under- 
going division, their nuclei presenting atypical karyokinetic figures, 
which he regards as pathognomonic of carcinoma. Cover-slip prep- 
arations are made from the sediment, dried in the air, fixed by 
immersion for an hour in a mixture of equal parts of absolute 
alcohol and ether, and stained with a dilute solution of hematoxylin. 

In cases of neoplasm Quincke T has drawn attention to the occur- 
rence in the fluid of large numbers of fat-droplets, which may attain 
a diameter of from 40 a to 50 u. At times, however, the fat- 
droplets are so small and numerous as to give a chylous appearance 
to the exudate. At other times a similar appearance is due to the 
presence of minute albuminous granules, which may be readily dis- 
tinguished from the former by their insolubilitv in ether. The 
occurrence of numerous fatty acid crystals arranged in groups should 
likewise be regarded as favoring the diagnosis of carcinoma. It is 
also claimed by Quincke that carcinoma probably exists if a marked 
glycogen reaction can be obtained in the endothelial cells. This 
test has been described in the chapter on the Blood (see page 52). 

Putrid Exudates. 

Putrid exudates are observed following perforation of a gangren- 
ous focus or of a gastric or intestinal ulcer into one of the body- 
cavities. At other times they are encountered in cases of neoplasm, 
and at times even without apparent cause. The material obtained 
in such cases has a brown or brownish-green color, and emits an 
odor which in itself indicates the character of the exudate. Micro- 
scopically, cholesterin, hasniatoidm, and fatty acid crystals, as well 
as degenerating leucocytes, are found. In cases in which aspiration 
of a higher intercostal space reveals the presence of serous fluid, 
while putrid material is obtained at a lower point, the existence of a 
subphrenic abscess should be suspected. In such cases a pure cult- 
ure of the Bacillus coli communis has been obtained. The reaction 
of putrid exudates is usually alkaline, but an acid reaction may be 
obtained in cases of perforation of a gastric ulcer ; the Sarcina ven- 
triculi and saccharomyces may then also be found. 

Pus. 

General Characteristics of Pus. — If pus, which usually pre- 
sents a color varying from yellowish gray to greenish yellow, is 
allowed to stand for some time, a liquid gradually appears at the 
top, and increases in amount until it is finally possible to distinguish 
two distinct layers, the one above — the pus-serum, the other at the 
bottom-^-the pus-corpuscles. Upon the number of the latter the 

1 Quincke, Deutsch. Arch. f. klin. Med... 1S82, vol. xxx. pp. 369 and 580. Rieder. 
Ibid.. 1895, toI. liv. p. 544. 



EXUDATES. 551 

consistence as well ae the specific gravity of the pus is dependent. 
This may vary between L.020 and 1.040* with an average of 1.031 

to 1.033. Fresh pus has always an alkaline reaction, which may 
become neutral or slightly acid upon standing, owing to the develop- 
ment of tree fatty acid-, glycerin-phosphoric acid, and lactic acid. 
The color of pus-serum may be a light straw, a greenish or a 
brownish yellow. 

Chemistry of Pus. — The chemical composition of pus-serum 
and pus-corpuscles may he seen from the following tables: 

Analysis of Pus-serum. 

r. ii. 

Water 913.70 905.65 

Solids 86.30 94.35 

Albumins 63.23 77.21 

Lecithin 1.50 0.56 

Fat 0.26 0.29 

Cholesterin 0.53 0.87 

Alcoholic extract 1.52 0.73 

Aqueous extract 11.53 6.92 

Inorganic salts 7.73 7.77 



Analysis of Pus-corpuscles. 

I. II. 

Xuclein 342.37 ) 

Insoluble matter 205.66 \ 673.69 

Albumins 137.62 J 

^f thin1 143.63 | ^.64 

r at i ( / o.OO 

Cholesterin 74.00 72.83 

Cerebrin 51.99 \ in9fi4 

Extractives 44.33/ iU - fe4 

Albumoses are usually present, and are derived from the pus-cor- 
puscles. Leucin and tyrosin are likewise frequently met with in the 
pns of old abscesses ; and fatty acids, urea, sugar, glycogen, biliary 
pigments and acid- (in catarrhal jaundice), acetone, uric acid, xanthin- 
bases, cholesterin, etc., have occasionally been observed.' 

Microscopical Examination of Pus. — Leucocytes. — If a drop 
of pus i- examined with the microscope, it will be seen to contain 
innumerable leucocytes, the diameter of which varies from S u. to 
10 ft, and which in fresh pus exhibit amoeboid movement.-. It Is 
curious t«» note that the so-called lymphocytes do not occur in pus, 
and even in the rare cases in which a predominance of this variety 
is met with in the blood, as in cases of lymphatic leukaemia, only 
the larger forms occur in the pus of abscesses which may have 
formed. While the leucocytes of fresh pus usually present a nor- 
mal appearance, specimens may be observed in which amoeboid move- 
ments can no longer be observed, even upon the application of heat, 

1 M. Pickardt, " Z. Kenntniss d. Chemie path. ErgusBe," Berlin, klin. Woch., 1897, 
p. 844. 



and in wMch rounded vacuoles, filled with a dear liquid, and fatty 

granulations in moderate numbers, may be seen. A predominance 
of such dead leu : - usually indicates that the pus is old or has 
formed in greatly debilitated subje :~ 

Owin _ : - rorpdon of water from acenmnlations of pus of long 
stan ling, sach material finally assumes a caseous aspect, and the 
leucocytes will be -een to have gieatly diminished in size, and to 
z -- : : — :._: . :_ :. ^ :. . -zzr: : z _ Z'zzzzzzz :-- : :: :- ~^-z _:.::_" 

ssihle : lemonstrate the piesence of a nucleus, even after the 
addition of acetic acid, 

It is noteworthy that in - ~ I nepotic abscess referable to the 
Amoeba coli it is seldom possible t remonstrate any normal lenco- 
ad it will be seen that under such conditions the pus con-: «:« 
essentially of granular and fatty detritus, while in liver-abscc - bh 
due to other causes the leucocytes usually present a ifairly normal 
appearance. 

In gonorrhoea! pus eosinophilic leucocytes are frequently found. 
Dr. E. Owings, who studied this question in my laboratory, was led 
to the following conclusions : 

1. Eosinophil:: .7 ~~— :;: 7 - T .: iz _ z :___ --. . > :.. 
large percentage of cases. They may be absent, however, even when 
a marked hyperleucocytosis and eosinophilic exist in the blood. 

2. Their number varies pari pamu with the number present in 
the blood, and the percentage in the pus is never in excess of the 
percentage in the blood. 

3. Gonoeocei are rarely found in eosinophilic leucocyte- 

As has been pointed out, eosinophilic leucocytes are also found 
in the sputum, and are especially abundant in cases of bronchial 
asthma and emphysema. 

Mast-cells ar-r ::_~ -x v-pd : xz'lj seri: ::: r~s. 

Giant Corpuscles. — So-called giant pus-corpuscles, measuring at 
times from 30 p. to -40 p. in diameter, have been observed in ab- 
sc-esse- : ~zi~ z'zzz z~ pp :: _. Ir. :hr . :.::t::> : ----■--; :;.__• 
ovarian cysts, but they do not appear to have any special significance. 
Upon careful examination these bodies will be seen to contain one 
oval nucleus, usually located eccentrically within the cell, and from 
one to thirty -.■_ forty pus-corpuscles. 1 

Detritus. — Fatty and albuminous detritus in variable amount 
may be observed in every specimen of pus, and increases with the 
length of time it has been confined within the body. The same 
hold- g : r the presence of free nuclei, which were formerly re- 
j : I- . > " ::.j " :>-:-' :t v. s:>s. ' ::: ~'zl-:'z L: ~r z.:~ ":•—:. .-zzz::~-~ 
irnized as originating during disintegration of the corpuscles. 

Red Corpuscles. — Red blood-corpuscles in variable numbers are 
usually seen in every specimen, their appearance depending upon the 

5 Bottcher, Yireliow's AtcMt, 1*67. to! yxtjx. jl 512L HJMHMffarm^ kc etiL 



EXUDATES. 553 

length of time they have been confined. Pus-corpuscles may al 
times contain a red corpuscle. 

In doubtful cases it is always well to search carefully for the 
presence of tissue-elements, as only in this manner is it possible al 
times to recognize the character of the morbid process. As the data 
of importance have been detailed in other sections of this book 
(viz., Sputum ami Urine), it is unnecessary to recapitulate at this 
place. 

Pathogenic Vegetable Parasites. — Of the pathogenic organisms 
which are of especial interest from a clinical standpoint may be 
mentioned the true pus-organisms, notably the Staphylococcus 
pyogenes aureus and the Streptococcus pyogenes ; furthermore, 
the tubercle bacillus, the Actinomyces hominis, the bacillus of 
glanders, the bacillus of anthrax, leprosy, tetanus, influenza, and 
FrankePs pneumococcus, etc. The majority of these have already 
been described, and the reader is referred for more detailed informa- 
tion to special works on bacteriology. In this connection it will 
suffice to state that, so far as pleural exudates are concerned, an 
absence of micro-organisms is usually indicative of tuberculosis, 
while the presence of FrankePs pneumococcus in exudates forming 
in the course of a pneumonia appears to be a favorable omen as 
regards the origin of the pleuritic effusion. 1 

Protozoa, with the exception of the Amoeba coli, have only rarely 
been found. Kunstler and Pitres 2 observed numerous large spores 
with from ten to twenty crescentic corpuscles in pus taken from the 
pleural cavity of a man, which closely resembled the coccidia of 
mice. Litten 3 observed cercomonads in fluid withdrawn from a 
pleural cavity. Trichomonads have been found in a case of em- 
pyema. 

Most important in this connection is the demonstration of the 
Amoeba coli in the pus, and in cases of liver-abscess an examination 
with this view should never be neglected, as the prognosis will to a 
large extent depend upon the results obtained. So far as the occur- 
rence of amoebae in pus is concerned, the observation of Flexner, 
who demonstrated their presence in an abscess of the lower jaw, 
-hows that they should not be looked for in the pus of abscesses of 
the liver or lung only. 

Vermes. — Of these, the filaria and hydatids are rarely observed 
in this country. Bothriooephalue leguloides has been found in the 
pleural cavity of a Chinese patient. 

Crystals. — A- has been stated, crystals of cholesterin are fre- 
quently found in old pus and in exudates of long standing, but are 

1 Lndwig Ferdinand v. Ilayorn. Arch. f. klin. Med., 1892, vol. 1. p. 1. Frankcl, 
Charite Annal.. 1888, vol. xiii. p. 1 17. 

- Kunstler a. Pitres, Compt. rend, de la 8oc. de Biol., 1884, p. 523. 

3 Litten, Verhandl. d. Cong. f. inn. Med., 1886, vol. v. p. 417. 



554 TRANSUDATES AND EXUDATES. 

rarely seen in recent exudates. They may be recognized by their 
characteristic form and their chemical reactions, as described in the 
chapter on the Feces (page 218). Triple phosphates, fatty acid 
crystals, and hgeroatoidm are likewise frequently seen, the presence 
of the latter, of course, indicating a previous admixture of blood. 

Chylous and Chyloid Exudates. 

Chylous and chyloid exudates have been repeatedly observed. 
They are most frequently met with in the abdominal cavity (one 
hundred and four times out of the total number of one hundred and 
fifty-five, which have thus far been reported), less commonly in the 
pleural cavity (forty-nine times), and only rarely in the pericardial 
sac (twice only). Quincke believes that the two forms can be 
etiologically distinguished from one another by means of a micro- 
scopical examination, as the cloudy appearance in the chyloid form 
is usually referable to the presence of endothelial or epithelioid cells 
undergoing fatty degeneration. Later observations, however, have 
shown that the differentiation of the two forms cannot be made upon 
this basis, as the same anatomical lesion, such as carcinoma, may at 
times give rise to the formation of a chylous exudate, at others to 
that of the chyloid form, and both, moreover, may coexist. 

Senator claimed that the presence of more than mere traces of 
sugar is strongly suggestive of the chylous nature of the exudate. 
Possibly this observation may be of some value, but it must not be 
forgotten that sugar is commonly met with in all forms of trans- 
udates and exudates. Only the presence of more than 0.2 per cent. 
is of value. 

Chylous exudates in their general appearance resemble milk, while 
chyloid fluid is more suggestive of pus. The turbidity in both cases 
is usually referable to the presence of innumerable fat-globules, 
which are especially abundant in the chylous form. In chyloid 
exudates the origin of the fat from cellular elements is often appar- 
ent at once ; but, as has been said, it is impossible to draw definite 
etiological conclusions from that difference. Some chyloid exudates 
contain no fat at all, and Lion has shown that the milky appearance 
in such cases is owing to the presence of a curious albuminous 
substance, belonging to the class of nucleo-albumins. 

Literature. — Quincke, loc. cit. Boulengier. Schmidt's Jalirb., 1890, vol. ccxxvi. 
p. 28. 



CHAPTER IX. 

THE EXAMINATION OF CYSTIC CONTENTS. 

CYSTS OF THE OVARIES AND THEIR APPENDAGES. 

The material obtained from cysts of the ovaries or their appen- 
dages varies greatly in character. On the one hand, it may be 
fluid, clear, of low specific gravity, and contain little albumin ; 
while, on the other, it may be dense, viscous, of colloid appearance, 
and have a specific gravity varying between ].018 and 1.024, owing 
to the presence of a large amount of albumin, viz., serum-albumin, 
serum-globulin, and, most important of all, metalbumin or paralbu- 
min. The latter is almost constantly met with in ovarian cysts, and 
its presence is characteristic of fluids derived from this source. 1 

Test for Metalbumin. — The fluid is mixed with three times its 
volume of alcohol and set aside for twenty-four hours, when it is 
filtered and the precipitate suspended in water. This is again 
filtered and the nitrate tested in the following manner : 1. A few 
cubic centimeters are boiled, when in the presence of metalbumin 
the liquid will become cloudy, without the formation of a precipitate. 
2. With acetic acid no precipitate is obtained. 3. Upon the appli- 
cation of the acetic acid and potassium ferrocyanide test the liquid 
becomes thick and assumes a yellowish color. 4. When boiled with 
Millon's reagent a few cubic centimeters of the filtrate will yield a 
bluish-red color, while the addition of concentrated sulphuric acid, 
without boiling, gives rise to a violet color. 

The color of cystic fluids may vary from a light straw to a reddish 
brown, or even a chocolate ; the latter color may be observed when 
hemorrhage lias taken place into the cyst. 

Of morphological elements, ovarian cysts contain red blood-cor- 
puscles, leucocytes, and ;it time- fatty granules in large numbers, 
crystals of cholesterin, haematoidin, and fatty acids. Most im- 
portant, however, from a diagnostic standpoint i- the presence of 
cylindrical or prismatic ciliated epithelial cells, derived from the 
internal lining of the cyst, in the presence of which the diagnosis 
may be definitely made (Fig. 130). At times such cell- cannol be 
demonstrated, as they may have undergone fatty degeneration ; 
moreover, if the epithelium lining the cysl is squamous in charact< r, 
it may be difficult, if not impossible, to arrive at a satisfactory con- 

1 Harnmersten, Zeit. f. physiol. Chem., L882, vol. \i. p. 194. 



556 



THE EXAMINATION OF CYSTIC CONTENTS. 



elusion from an examination of the morphological elements alone. 
Colloid concretions, which may vary in size from several micromil- 
limeters to 0.1 mm., are occasionally observed, and more particu- 
larly in colloid cysts. They may be recognized by their irregular 
form, homogeneous appearance, slightly yellow color, and delicate 
outlines. 

In dermoid cysts, epidermal cells and occasionally hairs are 
observed. 

The differential diagnosis of ovarian, parovarian, and fibrocystic 
(uterine) cysts cannot always be made from the character of the fluid 
withdrawn by puncture, but at times it is possible. The most im- 



portant points of difference are here given : 

Fig. 130. 



1. The fluid in ovarian 




Contents of an ovarian cyst. (Eye-piece III., obj. 8 A, Reichert.) (v. Jaksch. 
a, Squamous epithelial cells; b, Ciliated epithelial cells; c, Columnar epithelial cells; 
d, Various forms of epithelial cells ; e, Fatty squamous epithelial cells; /, Colloid bodies; 
g, Cholesterin-crystals. 

cystomata is usually more or less viscid, and often contains non- 
nucleated granular corpuscles of about the size of leucocytes, the 
granules of which do not dissolve in acetic acid nor disappear when 
treated with ether. In all probability they are free nuclei ; in the 
United States they are often called Drysdale's corpuscles. 2. In 
parovarian cysts the fluid is thin, watery, of low specific gravity 
(under 1.010), and contains very few morphological elements. 
Cylindrical epithelium is very rarely found during life in the fluid 
withdrawn by aspiration from either ovarian or parovarian cysts. 
3. The fluid from fibrocystic tumors of the uterus is thin, watery, 
and coagulates spontaneously, while that from ovarian and paro- 
varian cysts never coagulates spontaneously unless blood is present. 
Fibrocystic tumors of the uterus have no epithelial lining. 



HYDATID AND PANCREATIC CYSTS. 557 

HYDATID CYSTS. 

Hydatid cysts are scarcely ever seen in the United States. The 
fluid in question is clear, alkaline, of a specific gravity varying 
between 1.006 and 1.010, and contains no albumin. Succinic acid is 
usually present, and may be demonstrated by acidifying a small amount 
of the fluid with hydrochloric acid and evaporating to dryness. The 
residue is extracted with ether and the ether evaporated ; the aqueous 
solution of the second residue, in the presence of succinic acid, will 
yield a rust-colored gelatinous precipitate when treated with a few 
drops of a solution of ferric chloride. Sodium chloride is always 
present in notable amounts, and may he recognized by evaporating 
a drop of the liquid upon a slide, when the characteristic crystal- of 
-alt will be found. 1 Most important, of course, is the microscopical 
examination, which may reveal the presence of hooklets and shreds 
>>f membrane, and at times of scolices (see Sputum). 

HYDRONEPHROSIS. 

The diagnosis of hydronephrosis can usually be made without diffi- 
culty if a sufficient amount of fluid can be obtained ; the presence of 
urea and uric acid in notable quantities, as well as of renal epithelial 
cells, which latter especially should be sought for, is quite character- 
istic. Small amounts of uric acid, however, may also be present in 
ovarian cysts. 

PANCREATIC CYSTS. 

These cysts may be recognized by the fact that the fluid possesses 
the power of digesting albumin in alkaline solution. A small 
amount of the liquid is added to milk, when after precipitation of 
the casein the biuret test is applied ; a positive reaction indicates 
the presence of trypsin. Unfortunately, however, the test does not 
always yield positive results, even if the fluid in question is derived 
from a pancreatic cyst, as the trypsin is apparently destroyed in the 
course of time. The larger the cyst, the less likely will it be pos- 
sible to obtain the reaction. A positive result is hence only of 
value, while a negative result does not exclude the existence of the 
disease. 2 

1 J. Munk, Virchow's Archiv, 1875, vol. lxiii. p. 255. 

-Karewski, Deutsch. med. Woch., 1890, vol. xvi. pp. 103;") and 1069. Hofmeister 
Prag. med. Woch., 1891, vol. xvi. pp. 305 and 377 (see Gussenbauer). v. Jaksch, Zeit. 
f. Heilk., 1888, vol. ix. p. 126 (see Wolfler). 



CHAPTEE X. 
THE CEREBROSPINAL FLUID. 

According to our present knowledge, the cerebrospinal fluid is 
secreted by the choroid plexuses into the lateral ventricles. Passing 
through the foramina of Monro, the third ventricle, and the aque- 
duct of Sylvius, on the one hand, it reaches the fourth ventricle and 
enters the cistern-like subarachnoid spaces at the base of the brain, 
through the foramen of Magendie and the lateral clefts of the fourth 
ventricle. On the other hand, a certain portion of the fluid reaches 
the same destination directly through the cleft in the descending horn 
of each lateral ventricle. The larger portion of the fluid then passes 
upward through the subarachnoid spaces along the convexity of the 
brain to the Pacchionian granulations, while the smaller portion 
enters the vertebral canal through the subarachnoid spaces of the 
spinal arachnoid membrane. 

Within recent years puncture of the vertebral canal has been 
frequently resorted to, both for therapeutic and diagnostic purposes. 
The practical value of this method of diagnosis is now beyond ques- 
tion, and it is to be hoped that ere long physicians will resort to 
spinal puncture in obscure cases of cerebrospinal disease with as 
little hesitancy as puncture of the thoracic and abdominal cavities is 
now practised. 1 

The operative method to be employed is the following : with the 
patient placed upon his left side, — some observers prefer the sitting 
posture, — and the body bent well forward, a long aspirating-needle 
is introduced upon a level with the lower third of the third or fourth 
lumbar spinous process, and about 1 cm. to the side of the median 
line, the needle being directed slightly upward and inward. The 
depth to which it is necessary to puncture will, of course, vary with 
the age of the patient. In a child two years of age the vertebral 
canal may be reached at a depth of 2 cm., while in the adult it is 
necessary to insert the needle for a distance of from 4 to 8 cm. As 
soon as the subarachnoid space is reached cerebrospinal fluid will 
flow from the needle. Aspiration should always be avoided. 

Some writers have advised that the operation be performed under 

1 H. Quincke, Verhandl. d. X. Cong. f. inn. Med. 1891. A. Hand, "A Critical 
Summary of the Literature on the Diagnostic and Therapeutic Value of Lumbar 
Puncture." Am. Jour. Med. Sci., 1900. vol. cxx. p. 463. A. Stadelmann, " Klinische 
Erfahrungeu mit d. Lumbalpunction," Deutsch. med. Woch., 1897, p. 745. 

558 



THE CEREBROSPINAL FLUID. 559 

narcosis; and without doubt tins may be necessary at times, particu- 
larly when contracture of the dorsal muscles exists. In the majority 
of cases, however, it is not necessary. 

Amount. — So far as I have been able to ascertain, do observations 

have been made regarding the amount of fluid which mav be obtained 
by puncture in normal individuals. In all probability, however, thi- 
is small. Under pathological conditions the amount may vary from 
a tew drops to 1<»<) c.c, and even more. In general term- it may 
be stated that the amount is directly proportionate to the degree of 
intracranial pressure. Exceptions, however, are frequent. Small 
amounts of cerebrospinal fluid or none at all may thus be obtained 
when owing to the formation of a thick exudate or the existence of 
a cerebral tumor communication between the basilar subarachnoid 
spaces of the brain and those of the spinal cord has been interrupted. 
Whenever, then, symptoms of intracranial pressure exist, while no 
fluid or minimal amounts only can be obtained by puncture, the 
conclusion will usually be justifiable that we are dealing with a 
purulent meningitis or with a tumor of the brain, and more especially 
of the cerebellum. It should be remembered, however, that the 
same result may be obtained in cases of obliteration of the aqueduct 
of Sylvius, or when sclerotic processes involve the foramen of 
Magendie, which is occasionally observed in certain forms of hydro- 
ccphalus. Adhesions of the pia mater to the arachnoid and the 
dura mater may, by interfering with the flow of cerebrospinal fluid, 
also lead to the formation of hydrocephalus, but in these cases a 
tumor can usually be excluded, as the changes in question always 
develop as -equela? to a meningitis. A serous or tubercular menin- 
gitis, as well as acute hydrocephalus and tetanus, cau, however, 
always be excluded when only minimal amounts of fluid are obtained 
by puncture. The largest amounts, on the other hand, are seen in 
cases of serous meningitis, tubercular meningitis, and cerebral tumors, 
which do not interfere with the circulation of the cerebrospinal 
fluid. 

Appearance. — Normal cerebrospinal fluid, as well as that obtained 
in cases of serous meningitis, tubercular meningitis, hydrocephalus, 
and tumor- of the brain, i- perfectly clear, and a- ;i rule colorless 
unless a -mall blood-vessel has been punctured, when the fluid may 
present a -lightly reddish tinge. More or less pronounced yellow 
shades are, however, at time- observed. Important from the stand- 
point of diagnosis is the fact that in cases of hemorrhage into the 
ventricles pure blood i< obtained, while such a re-ult i-. of course, a 
mechanical impossibility in cases of epidural hsematoma. In subdural 
hsematoma, on the other hand, blood may also find its way into the 
subarachnoid -pace, but the amount i- always -mall, and cannot be 
compared with that seen in cases of ventricular hemorrhage. When- 
ever, then, as in traumatic cases with severe cerebral symptoms, the 



560 THE CEREBROSPINAL FLUID. 

surgeon is confronted with the question whether or not to trephine, 
puncture of the subarachnoid space may furnish much valuable 
information. If in such cases no blood at all is found, it may be 
inferred that an epidural hematoma or a subdural hseniatonia of 
slight extent only exists ; an operation may then be performed. If, 
however, pure blood is encountered, it would be justifiable to assume 
the existence of extensive injury to the brain-substance proper, 
or, in cases in which the history is obscure, an intracerebral hem- 
orrhage with rupture into the ventricles. In such cases the idea 
of an operation would, of course, be entertained only under excep- 
tional conditions. If, further, the fluid is only tinged with blood, 
a subdural hematoma probably exists, aud an operation should 
be advised. Accidental hemorrhage, viz., hemorrhage referable to 
the puncture itself, can be readily recognized, as the first few drops 
only are then tinged with blood, or the blood appears only after the 
flow has been definitely established ; the amount, moreover, is insig- 
nificant. 

Cloudy fluid is obtained in all cases of purulent meningitis unless 
the disease is limited to a very small area. This is, of course, most 
important from a diagnostic standpoint. Cases of abscess of the brain 
or sinus thrombosis occur again and again in which the question as 
to the advisability of operative interference is largely dependent 
upon the presence or absence of a complicating purulent meningitis. 
In certain instances a satisfactory conclusion may, of course, be 
reached without puncture ; but in many others this is impossible, 
and Lichtheim's dictum, that an operation should never be under- 
taken in such cases unless the integrity of the meninges has been 
established by spinal puncture, should be borne in mind. 

The degree of cloudiness naturally varies in different cases, and 
while in some instances the character of the fluid is seropurulent, 
pure, creamy pus may be found in others. Generally speaking, a 
cloudy fluid indicates the existence of an acute inflammatory process 
or an exacerbation of a chronic process. 

Important, furthermore, is the fact that the fluid in non-inflam- 
matory diseases of the brain, such as tumor or abscess, rarely 
undergoes coagulation, while this is the rule in all inflammatory 
diseases. In tubercular meningitis the coagula are very delicate, 
and may be well compared to spider-w T ebs extending throughout 
the fluid, while in purulent meningitis the coagula are much firmer. 

Specific Gravity. — The specific gravity of cerebrospinal fluid 
normally varies between 1.005 and 1.007, corresponding to the 
presence of from 10 to 15 pro mille of solids. Under pathological 
conditions variations from 1.003 to 1.012 may be observed, the 
specific gravity, generally speaking, being higher in the inflamma- 
tory than in the non-inflammatory diseases of the brain. From a 
diagnostic standpoint, however, the determination of the specific 



CHEMICAL COMPOSITION. 561 

gravity is of little value, as numerous exceptions to the above; rule 
occur. 

The reaction is always alkaline. 

Chemical Composition. — An idea of the chemical composition of 
the cerebrospinal fluid may be formed from the following analysis, 
taken from ( Jautier : 

Water 987.00 

Albumin 1.10 

Fat 0.09 

Cholesterin 0.21 

Alcoholic and aqueous extract, minus salts 1 2 7r - 

Sodium lactate I " 

Chlorides 6.14 

Earthy phosphates 0.10 

Sulphates 0.20 

In addition, urea is at times found, as also a substance which 
reduces Fehling's solution and gives rise to a brown color when 
boiled with caustic potash, but which neither undergoes fermentation 
nor forms an osazon when treated with phenylhydrazin. The sub- 
stance in question is generally regarded as pyrocatechin. Its amount 
varies between 0.002 and 0.116 per cent. According to C. Ber- 
nard, glucose may also be present, but it is questionable whether 
this is the case under normal conditions (see below). Nawratzki 
discovered a reducing substance in his cases, which was demon- 
strated to be glucose ; his subjects, however, were unfortunately not 
normal, but general paretics with fever. Pyrocatechin was absent. 
So far as the albuminous bodies are concerned which may be found 
in the cerebrospinal fluid, serum-albumin is said to be present only 
under exceptional conditions, while normally a mixture of globulin 
and albumoses is found. The question whether or not mucin may 
also be present is still undecided. 1 

Under pathological conditions the amount of albumin may vary 
considerably, and is of diagnostic importance. According to the 
majority of observers, the figure given in the above analysis is 
too high, and it is doubtful whether 1 pro mille may be regarded as 
normal. The lowest values have been obtained in cases of chronic 
hydrocephalus (traces only), meningitis serosa (0.5 to 0.75 pro mille), 
and tumors of the brain (traces to 0.8 pro mille); while the Largest 
amounts have been found in chronic hydrocephalus the result of 
hyperemia (1 to 7 pro mille), and in tubercular meningitis (1 to 3 
pro mille). Nawratzki in recent examinations found amounts varying 
between 0.047 and 0.170 per cent., but the subjects of bis investi- 
gation had fever at the time. 

Lichtheim claims to have found glucose — by means of the phenyl- 
hydrazin test — in all cases of tumor which he examined. In cases 

1 Stadelmann, Mitth. a. d. Grenzgebiet. d. Med. u. Chir., vol. ii. Comba, Clin, med., 
1899 (cited in Arch. d. M6d. d. Entente, 1900). Lenhartz, Verhandl. d. XIV. Cong. 

f. inn. Med., 1900. 

36 



562 THE CEREBROSPINAL FLUID. 

of tubercular meningitis, on the other hand, a positive result was 
only exceptionally obtained. Quincke also reports that he was able 
to demonstrate the presence of sugar whenever the liquid obtained 
was sufficient in amount for the necessary tests. Unfortunately, 
however, he does not detail his cases. Concetti found no sugar in 
hydrocephalic fluid. 

The experience of other observers does not agree with that of 
Lichtheim and Quincke ; and Furbringer, 1 who has thus far reported 
the largest number of spinal punctures, found sugar in only two 
cases of diabetes associated with tuberculosis. 

According to Gumprecht, the normal cerebrospinal fluid also con- 
tains traces of cholin. 

Microscopical Examination. — The microscopical examination 
of the fluid withdrawn by spinal puncture is most important. 

Under normal conditions, as well as in cases of tubercular men- 
ingitis, tumor, abscess, acute and chronic hydrocephalus, only a few 
leucocytes and endothelial cells from the subarachnoid spaces are 
usually found, enclosed in extremely delicate meshes of fibrin. In 
purulent meningitis, on the other hand, leucocytes are present in 
large numbers, and in some instances even pure pus may be obtained. 

Most important from a diagnostic standpoint is the fact that patho- 
genic micro-organisms may be found. Lichtheim, Furbringer, Frey- 
han, Dennig, and Frankel were thus able to demonstrate the presence 
of tubercle bacilli in a fairly large number of cases of tubercular 
meningitis. Other observers, it is true, have been less fortunate, 
but the fact that Furbringer found tubercle bacilli in thirty cases out 
of thirty-seven is certainly significant. Schwarz states that he ob- 
tained positive results in sixteen out of twenty-two cases, and 
Slawyk and Manicatide found bacilli in all of nineteen cases (six- 
teen times by direct microscopical examination, and three times by 
the animal experiment). In order to examine for tubercle bacilli, 
the fluid should be placed on ice for from six to twenty-four hours, 
until a slight coagulum has formed, when the fine, spider-web-like 
threads of fibrin are transferred to a cover-slip, spread in as thin a 
layer as possible, and stained as described in the chapter on the 
Sputum. If a centrifugal machine is available, the examination 
may, of course, be made at once ; the chances of finding the bacilli 
are then also much greater. In every case a large number of speci- 
mens should be prepared before the search is abandoned. Only a 
positive result, however, is of value, and in doubtful cases recourse 
should be had to the animal experiment. 2 

In the diagnosis of epidemic cerebrospinal meningitis lumbar 
puncture is of signal value, as the Diplococcus meningitidis intracellu- 
laris of Weichselbaum-Jager can be demonstrated in a large per- 

1 Furbringer, Verhandl. d. XV. Cong. f. inn. Med., 1901. 

2 Fiirbringer, loe. cit. Wentworth, Arch, of Pediat., Nov., 1899. 



MICROSCOPICAL EXAM IN A TION. 563 

centage of cases. Councilman l thus states that during a recent 
epidemic of the disease in Boston Lumbar puncture was performed 
in fifty-five cases, and that in the fluid obtained the diplococci were 
found on microscopical examination or in culture in thirty-eight 

cases. The average time from the onset of the disease before spinal 
puncture was made was seven days in the positive cases, and seven- 
teen days in the negative cases. The longest time after the onset 
in which a positive result was obtained was twenty-nine days. 
Similar results have also been reached by other observers. 2 

The organism in question is a diplococcus, each hemisphere being 
of about the same size as the ordinary pathogenic micrococci. It is 
readily stained with the usual dyes, and decolorized by Gram's 
method. Short chains of from four to six and tetrads may at times 
be seen. It grows best upon Loftier' s blood-serum mixture, form- 
ing round, whitish, shining, viscid-looking colonies, with smooth, 
sharply defined outlines, which may attain a diameter of from 1 to 
1 1 mm. in twenty-four hours. Their cultivation upon plain agar, 
glycerin-agar, and in bouillon is less reliable. 

In order to obtain the best results, it is necessary to use large 
amounts of the exudate, and to make a number of cultures, as 
many of the organisms are usually dead, or at least will not grow. 
In ordinary cover-slip preparations they are often numerous, and 
are found enclosed in the poly nuclear leucocytes. Their number 
then varies considerably. On the one hand, only one or two may 
be present in a cell, while in others they may be so closely packed 
a> to obscure the nucleus. 

Mixed infections are not uncommon in epidemic cerebrospinal 
meningitis. Councilman thus found the pneumococcus in seven 
cases, and Friedlander's bacillus in one. Terminal infections with 
staphylococci and streptococci also occur. 

In other forms of purulent meningitis a large variety of organisms 
has been found. Wolf gives the following figures, resulting from an 
analysis of 174 cases, in which epidemic cerebrospinal meningitis is, 
however, included : in 44. 2-) per cent, the pneumococcus was found ; 
in 34.48 per cent, the Diplococcus meningitidis intracellularis \ in 
3.45 per cent, staphylococci : in 8.03 per cent, streptococci, in 1.13 
per cent, the bacillus of Friedlanderj in 2.87 per cent, the Bacillus 
typhosus; in 1.72 percent, the bacillus of Neumann-Schaffer, and 
in 2.87 per cent, the Bacillus coli communis, the Bacillus pyogenes 
foetidus, the Bacillus aerogenes meningitidis, and the Bacillus mallei, 
while no bacteria were found in 1.15 per cent, of the cases. 

1 W. T. Councilman. "Cerebrospinal Meningitis," Johns Hopkins Eosp. Bull., 1898, 
p. 27: and Phila. Med. Jour., 1898, p. 937. W. T. Councilman, F. B. Mallory, and J. H. 
Wright, "Epidemic Cerebrospinal Meningitis." Am. Jour. Med. Sci., 1898, p 252. 

2 W. Osier, " The Cavendish Lecture on the etiology and Diagnosis of Cerebro- 
spinal Fever," Phila. Med. Jour., 1899, p. 26. E. Stadelmann, " Meningitis Cerebri 
spinalis," Zeit. f. klin. .Med., vol. xxxviii. p. 46. R. Neurath, CentralbL 1'. d. (irenz- 
gebiete d. Med. u. Chir., 1-!I7. vol. i. 



CHAPTER XI. 

THE SEMEN. 

The ejaculated semen is a mixture of the secretions furnished by 
the testicles, the prostate gland, the seminal vesicles, and the glands 
of Cowper. 

GENERAL CHARACTERISTICS. 

Semen is white or slightly yellowish in color, semifluid, sticky, 
and of an opaque, non-homogeneous, milky appearance, which is due 
to the presence of white, opaque islets floating in the otherwise clear 
fluid ; these consist almost entirely of the specific morphological 
elements of the semen, the spermatozoa. Its odor, which strongly 
resembles that of fresh glue, is characteristic, and is owing to the 
presence of spermin. It is generally attributed to an admixture of 
prostatic fluid, as the semen obtained from the vasa deferentia is 
odorless. According to Robin, however, this odor is produced only 
at the moment of ejaculation, and cannot be ascribed to any single 
one of the secretions present. The reaction of human semen is 
slightly alkaline, and its specific gravity greater than that of water, 
in which it sinks to the bottom. 

CHEMISTRY OF THE SEMEN 

Accurate analyses of human semen or of mammalian semen do 
not exist, and only the old analyses of Vauquelin and Kolliker 
can be given : 





Man. 


Horse. 


Ox. 


Water 


. . . 90 


81.90 


82.10 


Albuminous material ~\ 




r ... 


15.30 


Extractives .... f . 


• • • 6 


\ 16.45 




Ethereal extract . . J 




1 - 


2.20 


Mineral material . . . 


. . . 4 


1.61 


2.60 



The mineral matter consists largely of calcium phosphate. 

If semen is kept, or if it is slowly evaporated, crystals of phos- 
phate of spermin separate out, which are commonly known as 
Bottcher's crystals, and which were long regarded as identical with 
the so-called Char cot-Ley den crystals that are found in the sputum 
of bronchial asthma, in the blood of leukaemia, in the stools in cases 
of helminthiasis, etc. 

564 



MICROSCOPICAL EXAMINATION OF Till: SEMES. 



565 



Sperm in is a basic substance, and, according to Ladenburg and 
Abel, is closely related to, it' not identical with, diethylene diamin 
(piperazin) : 

Oft (,ir 4 

NtfH 

The phosphate crystallizes in the form of monoclinic four-sided 

spindles or prisms, which appear as flattened needles of variable 
size. Some are scarcely visible even with a fairly high power of 
the microscope, while others attain the length of 40 [i to 60 ji. 
The substance is soluble in formol, thus differing from Charcot- 
Leyden crystals. In water it dissolves with difficulty ; it is slowly 
soluble in acids and alkalies, even in ammonia, while it is insoluble 
in alcohol, ether, chloroform, and dilute saline solution. Florence's 
reagent (see below) colors the crystals a bluish black. According 
to Colin, the Bottcher crystals are formed exclusively in the prostate 
gland, the gland itself furnishing the basic component, while the 
necessary phosphoric acid is derived from other portions of the 
reproductive apparatus. 1 



MICROSCOPICAL EXAMINATION OF THE SEMEN. 

Upon microscopical examination normal semen is seen to contain 
innumerable actively moving thread-like bodies, measuring from 
50 (i to 60 fi in length — the spermatozoa. These consist, of an egg- 

Fig. 131. 




Human semen, 
a, Spermatozoa: &, Cylindrical epithelium; e, Bodies enclosing lecithin-grannies; d, 

Squamous epithelium from the urethra: d' , Testicle-cells ; e, Amyloid corpuscles : J, Sper- 
matic crystals; g, Hyaline globules, (v. Jak« b.) 

shaped head, when seen from above, which is from 3 u to 5 /t m 
length, the broader end being directed anteriorly ; a middle portion, 
4 n to 6 // in length, with which the head is united by its smaller 

1 Th. Cohn, " Zur Kenntniss d. Spermas," Centralbl. f. allg. Path. u. path. Anat., 
vol. x. pp. 940-949. 



566 THE SEMEN. 

end ; and a posterior piece or tail, into which the middle piece grad- 
ually fades (Fig. 131). 

In addition to the spermatozoa a few hyaline bodies are seen which 
are derived from the seminal vesicles ; further, numerous small pale 
granules of an albuminous nature, some testicular and urethral epi- 
thelial cells, lecithin-corpuscles, and so-called prostatic or amyloid 
corpuscles, which at first sight resemble starch-granules in appearance, 
owing to their concentric striations. A few leucocytes and occasion- 
ally a few red corpuscles may also be found. 

PATHOLOGY OF THE SEMEN. 

The study of the semen has received little attention from clini- 
cians, and gynecologists frequently hold the wife responsible for 
sterility when an examination of the husband's semen would — 
according to Kehrer, 1 in 40 per cent. — reveal an absence of sperma- 
tozoa, constituting the condition usually spoken of as azoospermatism. 
This may be temporarily observed following venereal excesses, when 
the fluid finally ejaculated is almost entirely of prostatic origin ; 
their absence then possesses no significance, but persistent azoosper- 
matism must of necessity be associated with sterility. 2 

Cases have been recorded in which, notwithstanding the presence 
of spermatozoa and apparently normal sexual conditions in both 
husband and wife, sterility existed nevertheless, but in which it was 
observed that the spermatozoa lost their motile power almost imme- 
diately after ejaculation. Under normal conditions, following inter- 
course actively moving spermatozoa may be found in the vagina 
after hours, days, and even weeks. 

Whenever it is deemed advisable to make an examination of the 
semen, this should be done immediately following ejaculation, or as 
soon as possible thereafter. Note should then be taken, not only of 
the presence, but also of the degree of motility of the spermatozoa ; 
a drop of the semen is mixed with a drop of normal (0.6 per cent.) 
saline solution, and examined at once with the microscope. 

Bloody semen, constituting the condition spoken of as hcemo- 
spermia, has been observed on several occasions. It may follow 
excessive sexual indulgence, but may also occur in connection with 
gonorrheal epididymitis. The blood is readily recognized upon 
microscopical examination. 

THE RECOGNITION OF SEMEN IN STAINS. 

In medico-legal cases the physician may be called upon to decide 
whether or not certain stains on body-linen are caused by spermatic 

1 Kehrer, Beitrage z. klin. u. exper. Gynaek., 1879, vol. ii., Giessen. 

2 Fiirbringer, Zeit. f. klin. Med., 1881, vol. iii. p. 310. 



THE RECOGNITION OF SEMEN IS STAINS. 567 

fluid, whether or not a rape has beeD committed, etc. In each cases 
it is frequently only necessary to examine a drop of the vaginal 
fluid in order to arrive at a positive result at once. At other times, 

however, recourse must be had to the following method : a fragment 
of the linen or scrapings from the vulva or vagina are placed in a 
watch-crystal and allowed to soak for at least one hour in from 27 
to 30 per cent, alcohol, when a hit of the material is teased iu a 
solution of eosin in glycerin (1 : 2(H)), and examined. The 
heads <>l' the spermatozoa are thus stained a deep red, while the 
tails, which are often broken, exhibit a pale-rose tint, and can 
readily be distinguished from vegetable fibres, which do not take 
the stain at all. A positive statement can thus be made in every 
case, even after months and years, as spermatozoa not only resist the 
action of reagent-, but also the process of putrefaction ; this is prob- 
ably owing to the large proportion of mineral matter which enters 
into their composition, and which insures preservation of their form. 
Instances have been recorded in which it was possible to demon- 
strate spermatozoa in stains after eighteen years. 

The semen test of Florence L has attracted much attention, and 
may be recommended in doubtful cases ; only a negative result, 
however, is of value (see below). It is based upon the observation 
that very characteristic crystals of iodospcrmin are formed when 
spermatic fluid is treated with a solution of iodo-potassic iodide 
containing 1.65 grammes of pure iodine and 2.54 grammes of 
potassium iodide, dissolved in 26 c.c. of water. When a drop 
of this solution is added to a drop of spermatic fluid or an aqueous 
extract of a seminal stain, dark-brown crystals of iodospcrmin sepa- 
rate out at once, and may be readily recognized under the microscope. 
They occur in the form of long rhombic platelets or fine needles, 
often grouped in rosettes, but also occurring singly or as twin 
crystals. The examination with the microscope should be made at 
once after addition of the reagent, as the crystals disappear on 
standing. 

As the reaction may also be obtained in eases of azoosperma- 
tism, and with pure prostatic secretion, while a negative result is 
obtained with the fluid from spermatoceles, it is manifest that the 
test is not applicable for the determination of the presence or ab- 
sence of spermatozoa per 8e. Posner 2 states that he obtained 
similar crystals when the test was applied to a glycerin extract of 
ovaries. 

More recently Richter has shows that Florence's reaction is also 
obtained with a decomposition-product of lecithin, viz., cholin, 

1 Florence. "Da snermc et des taches do sperme en m6decine legale," Arch. 
d'Anthrop. criruin., vols. x. and xi. 

2 C. Posner. " Die Florence'scbe Beaktion," Berlin, klin. Woe],.. 1897, p. 602. 

3 M. Richter, " D. mikrochemische Nachweia v. Sperma," Wien. klin. Woch., 1897, 

p. 569. 



■:"?S THE SEMTES. 

which would explain the observation that better results are com- 
monly obtained with dried semen than with fresh material. But 

i: z.'li'-x-i ;.--: :_:::_t :-:-:z::z :■£.:::::: :■- ; ?z*;i±-: ----- r-:;-::::::. 
and Richter accoixlingly conelndes that a negative result only ii 
value, and indicates that the material under examination is 
semen. He states that he obtained positive results with vaginal 
and uterine mucus, with decomposing brain-substance, and other 
organs as well. 



CHAPTER XII 



VAGINAL DISCHARGES. 



GENERAL CHARACTERISTICS. 

The secretion which is normally furnished by the vaginal glands 
is small in amount, and just sufficient to keep the mucous mem- 
brane moist. It is a clear or somewhat milky -looking, semiliquid 
material, in which numerous epithelial lamina?, which have been 
thrown off during the normal process of desquamation, may be 
found. It has been stated that the reaction of the vaginal secretion 
in virgins is invariably acid, while an alkaline reaction is the rule in 
the tUflorees. During pregnancy, however, the secretion is probably 
always acid. In five hundred cases which Kronig examined in this 
direction an alkaline reaction was never observed. According to 
Zweifel, the vaginal secretion contains traces of trimethylamin. 1 

Microscopically, numerous epithelial cells, mucous corpuscles, a 
few large mononuclear leucocytes cellular detritus, and bacteria are 
found (Fig. 132). Doderlein 2 has described a non-pathogenic 

Fig. 132. 




Vaginal secretion. 
a. Mucous corpuscles; b, Vaginal epithelium ; c, Epithelium from vulva. 

bacillus or a group of bacilli which are characterized by the fact 
that they give rise to marked acid fermentation of sugar, and he 
regards these organisms as the only ones which are constantly 
present in the normal vagina. Kronig and Menge, however, state 



1 Zweifel, Arch. f. Ovnaek., 1881, vol. xviii. p. 359. 

2 Doderlein, Ibid., 1887, vol. xxxi. p. 412. 



569 



570 VAGINAL DISCHARGES. 

that they are often absent. These observers have found, on the 
other hand, that under normal conditions there are various bacilli 
and cocci present which belong to the class of obligatory anaerobes, 
and are likewise non-pathogenic. Unfortunately they have not 
described these organisms in detail. Xear the outlet they found 
bacteria which may be cultivated upon alkaline aerobic eulture- 
media. but which are usually absent in the upper portion oi the 
vagina, 

Ir is important to note that various diplococci may also be found 
under normal conditions, and care shoidd be taken not to confound 
these with gonococci. Like the gonococci. they are decolorized by 
Gram's method. If the various characteristics of the former be 
borne in mind, however, mistakes may probably always be avoided : 
but in married women and in children it would be best to make 
the diagnosis of gonorrhoea only when the gonococcus has been iso- 
lated by cultivation. 

The question whether or not pathogenic bacteria may occur in the 
normal vagina of pregnant or non-pregnant women, may be an- 
swered in the affirmative : although it must be admitted that 
with the exception of the gonococcus they are only exceptionally 
found. 1 

The vaginal secretion has been shown to possess powerful bac- 
tericidal properties, so that pathogenic organisms, even when 
artificially introduced into the vagina, are rapidly killed. Kronig 
thus found that the Bacillus pyocyaneus disappears from the 
vagina of pregnant women in from ten to thirty hours, the 
staphylococci in from six to thirty-six hours, and the Strepto- 
coccus pyogenes within six hours. Important from a practical 
standpoint is the tact that the bacteria disappeared less rapidly 
when irrigation of the vagina with water or even antiseptics was 
employed. 

Of animal parasites, the Trichomonas vaginalis is apparently the 
only one which may be encountered in the vaginal discharge. The 
organism is identical with the trichomonas found in the feces and the 
urine. In this country it is not often observed, while it is common 
among the peasant population of Central Europe. As tar as is 
known, the organism is of no pathological significance, and may occur 
both under normal and pathological conditions. From a medico- 
legal standpoint, however, its presence may not be unimportant, as 

- - are on record in which trichomnnades have been confounded 
with spermatozoa. In my judo'tnem. however, such a mistake can 
only occur if the ob-erver is without microscopical training. 

1 rlein. Das Seheidenseeret, Leipzig. 1892. J. W. Williams, " Bacteria of the 
Vaginal Secretion of the Pregnant Woman." Am. Jour. Obstet.. 1898, vol. xxxviii. 
"The Bacteria of the Vagina and Their Practical Significance," Tran=. Am. Gyn. 
3oc 1898 " The Cause of the Conflicting Statements concerning the Bacterial Con- 
tents of the Vaginal Secretion of the Pregnant Woman," Am. Jour. Obstet.. 1898. 



VAGINAL BLENNORRH(EA—THE LOCHIA. 571 

VAGINAL BLENNORRHEA. 

In physiological conditions an increased vaginal secretion is ob- 
served during sexual excitement, ('specially during coitus, just pre- 
ceding and at the beginning of menstruation, and during preg- 
nancy, when a profuse blennorrhea is frequently seen, which often 
assumes a virulent character. The secretion under such conditions 
readily becomes purulent. When not dependent upon a gonorrhoea] 
infection the secretion is thicker than normal, white, and creamy. 
At times also the vaginal catarrh observed in pregnancy is com- 
plicated with mycosis, when white or yellowish-gray patches may 
be seen at the orifice of the vagina ; the latter may, indeed, even 
be tilled with particles which consist entirely of fungi. 

MENSTRUATION. 

At the beginning of menstruation, as has been pointed out above, 
an increase in the amount of vaginal secretion is observed, in which 
leucocytes, prismatic epithelial cells coming from the uterus, as well 
as the usual vaginal cells, may be seen upon microscopical exami- 
nation. Later the secretion becomes sanguineous in character, 
and finally only epithelial cells, leucocytes, and granular detritus are 
encountered, the cells usually showing evidence of fatty degenera- 
tion. The amount of blood lost at each menstrual period amounts 
to about 200 grammes in perfectly healthy females. 

THE LOCHIA. 

The lochia during the first day following parturition are red in 
color — the lochia rubra — and emit the characteristic sanguineous 
odor. At this time a microscopical examination will reveal an 
abundance of red corpuscles, some leucocytes, and a variable number 
of epithelial cells, which are almost exclusively of vaginal origin. 
On the second and third days the number of red corpuscles dimin- 
ishes, while the leucocytes increase in number. Still later the dimi- 
nution in the red and the increase in the white corpuscles become 
more marked, and the discharge at the same time assumes a grayish 
or white color, until about the tenth day the val corpuscles have 
almost entirely disappeared, while the leucocytes and epithelial cell- 
are abundant. Finally, the secretion becomes thicker, mucoid, and 
milky white in color — the lochia alba, which condition may persist 
for from three to four week- in nursing-women, and -till longer in 
those who do not nurse, until finally the normal secretion is again 
established. Numerous bacteria are encountered in the lochia, and 
it is curious to note that among these pus-organisms are quite con- 
stantly present without giving rise to symptoms. When a portion 



572 VAGINAL DISCHARGES. 

of the placenta or membranes have been retained the lochia soon 
give off a fetid odor, and assume a dirty brownish color ; the reten- 
tion of blood-clots alone may also produce this result. In such 
cases the lochia swarm with bacteria of all kinds. 1 

VULVITIS AND VAGINITIS. 

In cases of vulvitis and vaginitis a marked increase is observed 
in the number of the leucocytes and epithelial cells, the character of 
the latter depending, essentially of course, upon the portion of the 
genital tract affected. Red corpuscles are also met with at times ; 
their number generally stands in a direct relation to the intensity of 
the inflammatory process. In some instances epithelial casts of 
the entire vagina have been observed, constituting the condition 
termed vaginitis exfoliativa. The condition, however, is rare. 

The discharge of large amounts of pure pus through the vagina 
points to perforation of an abscess of the genital organs or of the 
neighboring structures into the uterus or the vagina ; it is of rare 
occurrence. Much more common is the discharge of fecal matter 
or of urine through this channel, indicating the existence of a 
vagino-rectal or vagino-vesical fistula. 

MEMBRANOUS DYSMENORRHEA. 

While ordinarily, during menstruation, shreds of desquamated 
uterine lining are frequently encountered, it is rare to meet with 
large pieces or complete casts of the uterus, the elimination of which 
is usually associated with the symptoms of a severe dysmenorrhea, 
constituting the condition spoken of as membranous dysmenorrhcea . 

CANCER. 

While the diagnosis of malignant growth of the uterus is probably 
never based upon a microscopical examination of the vaginal dis- 
charge alone, it may be mentioned that in advanced cases this is pos- 
sible, as fragments of an epithelioma of the cervix, for example, may 
frequently be detected upon microscopical examination (Fig. 133). 
In suspected cases small pieces of tissue should be removed and 
examined according to usual histological methods. 2 



2 



GONORRHOEA. 

In suspected cases of gonorrhoea an examination of the vaginal 
and urethral discharge for the presence of gonococci is important, 
as it is practically impossible to diagnose this condition posi- 
tively in any other manner. Care should be taken, however, not to 

1 Doderlein, loc. cit. Thomen, Centralbl. f. d. med. Wiss., 1890, vol. xxviii. p. 537; 
and Arch. f. Gyn., 1889. vol. xxxvi. p. 231. 

2 T. S. Cullen, Cancer of the Uterus, Appleton & Co., 1900. 







573 



Vaginal secretion from a case of epithelioma of the cervix uteri. 

confound the diplococci which may be normally present in the 
urethra and vagina with gonococci (see chapter on the Urine). 

ABORTION. 

In cases of abortion it is often possible to discover chorion villi in 
the expelled blood-clots which present the characteristic capillary 

Fig. 134. 




Chorion villi. 



574 



VA GISAL DISCHARGES. 



network (Tig. 134), and often manifest signs of advanced fatty 
degeneration. Important also from a diagnostic point of view is the 



Fig. 135. 




Decidual cells. 



presence of decidual cells (Fig. 135). which are characterized by 
their large size, their round, polygonal, or spindle-like form, and 
their characteristic nuclei and nucleoli. 



CHAPTER XIII. 
THE SECRETION OF THE MAMMARY GLANDS. 

THE SECRETION OF MILK IN THE NEWLY BORN. 

A secretion from the mammary glands of the male is observed 
only in the newly horn, if we except those rare cases in which 
adult males were known to suckle infants. The fluid in question, 
which may also be obtained from the female infant, is termed 
"Hexenmilch" (witches' milk) by the Germans. Qualitatively it 
has the same composition as milk, but may manifest considerable 
quantitative variations. 

COLOSTRUM. 

Aside from those curious instances in which a secretion of milk 
has been observed in non-pregnant women, mammary activity is 
essentially connected with the physiological phenomena of pregnancy 
and parturition. Often as early as the third month a small drop of 
a serous-looking fluid can be obtained from the nipple by pressure 
upon the breasts. Immediately after delivery a variable amount of 
fluid is secreted, which is watery, semi-opaque, mucilaginous, and 
of a yellowish color. To this secretion, as well as to that observed 
during pregnancy, the term colostrum has been applied. It is dis- 
tinguished from true milk by its physical characteristics and by the 
presence of a greater proportion of sugar and salts. The fluid, 
moreover, coagulates upon boiling. An idea may be formed of its 
composition from the appended table: 





4 week-- before birth. 


17 days be- 
fore birth. 


9 days be- 
fore birth. 


24 hours 
afterbirth. 


J -lays 
after birth 




I. 


II. 


Water . . . 


945.2 


852.0 


851.7 


868.8 




867.9 


Solids . . 


54.8 


148.0 


L48.3 


141.2 


1570 


132.1 


Casein . . . 










• • • 


21.8 


Albumin . . 


28.8 


69.0 


74.8 


80.7 






Fat .... 


7.3 


41.3 


30.2 


23.5 




48.6 


Lactose . . . 


17.3 


39.5 


43.7 


36.4 




61.0 


Salts .... 


4.4 


44 


4.5 


5.1 


5.1 





Upon microscopical examination fat-droplets, a few leucocytes, 

some epithelial cells, and so-called rofostrmn-rorpusclen are found. 



575 



576 



THE SECRETION OF THE MAMMARY GLANDS. 



Fig. 136. 



Q?-° -QS--„- .fey 



Colostrum of a woman in sixth month of pregnancy. (Eye-piece III., obj. 8 A., Reichert.) 

(t. Jxkscb..) 

The latter are highly refractive bodies, of irregular size, whose inte- 
rior is filled with fatty granules (Fig. 136). 

Liteeatuee.— G. Woodward, "Chemistry of Colostrum Milk," Jour. Exper. Med., 
vol. ii. p. 217. 

THE SECRETION OF MILK PROPER, IN THE ADULT 

FEMALE. 

The secretion of milk proper usually begins about the third day 
following parturition, and may continue for a variable length of 
time. On the one hand, the amount of milk secreted may be so 
small as to be insufficient for the needs of the child, so that lacta- 
tion may have to cease after several days; on the other hand, 
women are not infrequently seen who nurse their children for two 
years and even longer. Usually infants are nursed until six or seven 
teeth have appeared, which period varies with the individual child, 
averaging about the eleventh month. 



HUMAN MILK. 

Human milk is of a bluish color, and differs in this respect from 
the milk of cows. Its reaction is alkaline. The specific gravity 
may vary between 1.026 and 1.035, one between 1.028 and 1.034 
being the most common. The amount of milk secreted in twentv- 
four hours varies from 500 to 1500 c.c. Microscopically, it is a 
fairly homogeneous emulsion of fat, and is practically destitute of 
cellular elements. From the following table an idea may be formed 
of its chemical composition : 





Biehl. 


Gerber. 


Christenn. 


Pfeiffer. 


Pfeiffer. 


Mendes de 
Leon 


Water 


876.00 


891.00 


872.40 


892.00 


890.60 


877.90 


Solids 


124.00 


109.00 


127.60 


108.00 


109.40 




Albumin .... 


22.10 


17.90 


19.00 


16.13 


17.24 


25.30 


Fat 


38.10 


33.00 


43.20 


32.28 


29.15 


38.90 


Lactose 


60.90 


53.90 


59.80 


57.94 


59.92 


55.40 


Salts 


2.90 


4.20 


2.60 


1.65 


2.09 


2.50 



THE MILK IS DISEASE. 577 

Upon comparing this table with the following analysis of cows' 
milk it will be seen that the latter contains more albumin and less 
sugar than human milk. Unman milk, moreover, is relatively 

deficient in mineral matter, and especially in calcium salts and 
phosphoric acid : 

Water S74.2 

Solids 125.8 

Casein 28.8] QA , 

Albumin 5.3 J d4 ' 5 

Fat 36.6 

Lactose • 48. 1 

Salts 7.1 

The albumins found in milk-plasma are easem, lactoglobulin, 
and lactalbumin. It is claimed by some observers that the casein 
of human milk differs from that obtained from cows' milk. The 
casein-coagula in human milk arc not so large and dense as those 
observed in cows' milk. Human casein, moreover, is not so readily 
precipitated by acids and salts; it docs not always coagulate upon 
the addition of rennet ferment, and while it may be precipitated by 
the gastric juice, it is readily dissolved by an excess. Although 
accurate analyses of human casein are not available, it is probable 
that the two forms are not identical (Hammarsten). 

The question whether or not normal human milk contains micro- 
organisms may now be answered in the affirmative. There can be 
no doubt, however, that the milk as it is secreted by the healthy 
gland is sterile, but upon passing along the lacteal ducts in the 
nipple it is always contaminated by the Staphylococcus epidermidis 
albus (Welch). This micro-organism must be regarded as a constant 
inhabitant of the skin, and is the only one of the cutaneous bacteria 
which regularly penetrates into the deeper layers of the epidermis 
and into the glandular appendages of the skin. It is thus at once 
apparent why this organism is so constantly met with, and is prac- 
tically the only one found in normal human milk. Exceptionally 
the Staphylococcus pyogenes aureus is found. 

THE MILK IN DISEASE. 

The chemistry of the milk in pathological conditions has received 
little attention. It appears, however, that the milk of women when 
ill usually contains less fit, and that the proportion of lactose is 
diminished. Tn cases of jaundice the presence of bile-pigmenl and 
of biliary acids has not been satisfactorily demonstrated. Jn cases 
of mammary tumors bloody secretion has been observed in rare 
cases, the nipple itself being intact. 

Microscopically, an admixture of leucocytes is observed in various 
disease- of the breast, and especially in cases of abscess. Of patho- 
genic micro-organisms, streptococci may be found in cases of puer- 
37 



578 



THE SECRETION OF THE MAMMARY GLANDS. 



peral fever 



Fig. 137. 



more commonly, however, they are absent. The 
typhoid bacillus has occasionally been seen in 
cases of typhoid fever, and it is interesting to 
note that the specific agglutinins of typhoid fever 
have been noted in the milk. Pneumococci have 
been obtained from the milk of pregnant women 
affected with lobar pneumonia. The important 
question whether or not tubercle bacilli are elimi- 
nated in the milk in cases of phthisis cannot be 
definitely answered. In cows such an occurrence 
is certainly common, even when there is no demon- 
strable tubercular lesion of the udder. So far as 
I have been able to ascertain, however, tubercle 
bacilli have never been found in human milk. 1 

A blue and a red color have been observed 
in the milk of cows, owing to the presence of the 
Bacillus pyocyaneus and the Micrococcus prodig- 
iosus, respectively. 

A chemical examination of human milk should 
always be made whenever it is apparent that 
the nutrition of the baby is below normal. 
Valuable dietetic suggestions may thus be ob- 
tained. In other cases, as when the mother is 
unwilling or unable to nurse her child beyond a 
certain period, a knowledge of the composition of 
her milk will enable the physician to give specific 
instructions regarding the proper modification of 
cows' milk. If a wet-nurse is to be employed, 
her milk should likewise be examined. 

Most important is the determination of the 
specific gravity and of the amount of fat. The 
former may vary between 1.029 and 1.033. The 
amount of fat should not be less than 3 per cent. 



Determination of the Specific Gravity. 

The specific gravity is best determined with 
the lactodensimeter of Quevenne (Fig. 137). As 
the instrument is graduated for a temperature of 
60° F., it is necessary to correct the specific grav- 
ity whenever the temperature is above or is below 
this point. In the following tables the corrected 

specific gravity may be found corresponding to temperatures ranging 

from 46° to 75° F. : 




Quevenne's lactoden- 
simeter. 



1 Esckerich, Fortschr. d. Med., 1885, vol. iii. p. 321. Karlinski, Wien. med. Woch., 
1888, vol. xxxviii. No. 28. Ott, Prag. med. Woch., 1892, vol. xvii. p. 145. Cohn u. 
Neumann, Virchow's Archiv, 1880, vol. cxxvi. p. 187. 



THE MILK IX DISEASE. 
Corrections for Temperature. 



570 



Specific 


Degrees of thermometer (Fahrenheit). 


gravity 


4G 


47 


48 


49 


50 


51 


52 




54 


55 


1020 


19.0 


19.1 


19.1 


19.2 


19.2 


19.3 


19.4 


19.4 


19.5 


19.6 


1021 


20.0 


20.0 


20.1 




20.2 


20.3 


20.3 


20.4 


20.5 


20.6 


1022 


21.0 


21.0 


21.1 


21.2 


•J 1.2 


21.3 


21.3 


21.4 


21.5 


21.6 


1023 


22.0 


22.0 


22.1 


22.2 


22.2 


22.8 


22.8 


22.4 


22.5 


22.6 


1024 


22.9 


23.0 


28.1 


28.2 


23.2 


23.3 


23.3 


28.4 


23.5 


•j:<y> 


1025 


23.9 


24.0 


24.0 


24.1 


24.1 


24.2 


24.3 


24.4 


24 5 


24.6 


1026 


24.9 


24.9 


25.0 


25.1 


25.1 


25.2 


25.2 


25.3 


25.4 


25.5 


1027 


25.9 


25.9 


26.0 


26.1 


26.1 


26.2 


26.2 


26.3 


26.4 


26.5 


1028 


26.8 


26.8 


26.9 


27.0 


27.0 


27.1 


27.2 


27.3 


27.4 


27.5 


1029 


27.8 


27.8 


27.9 


28.0 


28.0 


28.1 


28.2 


28.3 


28.4 


28.5 


1030 


28.7 


28.7 


28.8 


28.9 


29.0 


29.1 


29.1 


29.2 


29.4 


29.4 


1031 


29.6 


29.6 


29.7 


29.8 


29.9 


30.0 


30.1 


30.2 


30.3 


30.4 


1032 


30.5 


30.5 


30.6 


30.7 


30.9 


31.0 


31.1 


31.2 


31.3 


31.4 


1033 


31.4 


31.4 


31.5 


31.6 


31.8 


31.9 


32.0 


32.1 


32.3 


32.4 


1034 


32.3 


32.3 


32.4 


32.5 


32.7 


32 9 


33.0 


33.1 


33.2 


33.3 


1035 


33.1 


33.2 


33.4 


33.5 


33.6 


33.8 


33.9 


34.0 


34.2 


34.3 



Specific 






Degrees of thermometer (Fahrenheit). 






gravity. 


56 


57 


58 


59 


60 


61 


62 


63 


64 


65 


1 120 


19.7 


19.8 


19.9 


19.9 


20.0 


20.1 




20.2 


20.3 


20.4 


1021 


20.7 


20.8 


20.9 


20.9 


21.0 


21.1 


21.2 


21.3 


21.4 


21.5 


1022 


21.7 


21.8 


21.9 


21.9 


22.0 


22.1 


22.2 


22.3 


22.4 


22.5 


1023 


22.7 


22.8 


22.8 


22.9 


23.0 


23.1 


23.2 


23.3 


23.4 


23.5 


1024 


23.6 


23.7 


23.8 


23.9 


24.0 


24.1 


24.2 


24.3 


24.4 


24.5 


1025 


24.6 


24.7 


24.8 


24.9 


25.0 


25.1 


25.2 


25.3 


25.4 


25.5 


1026 


25.6 


25.7 


25.8 


25.9 


26.0 


26.1 


26.2 


26.3 


26.5 


26.6 


1027 


26.6 


26.7 


26.8 


26.9 


27.0 


27.1 


27.3 


27.4 


27.5 


27.6 


1028 


27.6 


27.7 


27.8 


27.9 


28.0 


28.1 


28 


28.4 


28.5 


28.6 


1029 


28.6 


28.7 




28.9 


29.0 


29.1 


29.8 


29.4 


29.5 


29.6 


1030 


29.6 


29.7 


29.8 


29.9 


30.0 


30.1 


30.3 


30.4 


30.5 


30.7 


1031 


30.5 


30.6 


30.8 


30.9 


31.0 


31.2 


31.3 


31.4 


31.5 


31.7 


1032 


31.5 


31.6 


31.7 


31.9 


32.0 


32.2 


32.3 


32.5 


32.6 


32.7 


1033 


32.5 


32.6 


32.7 


32.9 


33.0 


33.2 


33.3 


33.5 


33.6 


33.8 


1034 


33.5 


33.6 


33.7 


33.9 


34.0 


34.2 


34.3 


34.5 


34.6 


34.8 


1035 


34.5 


34.6 


34.7 


34.9 


35.0 


35.2 


35.3 


35.5 


35.6 


35.8 



Specific 






Degrees of thermometer (Fahrenheit). 






gravity. 


66 


-•■7 


68 


69 


70 


71 


72 


::: 


74 


75 


1020 


20.5 


20.6 


20.7 


20.0 


21.0 


21.1 


21.2 


21.8 


21 5 






21.6 


21.7 


21.8 




22.1 


22.2 


2.'.;; 


22.4 


22.5 




lu22 


22.6 


•_>■' 7 


22.8 


23.0 


23.1 




28.8 


23.4 


23.5 




1023 


23.6 


23.7 


23.8 




24.1 


24.2 


24.3 


24 t 


24.6 


24.7 


1024 


24.6 


24.7 


24.9 


25.0 


25.1 


25.2 


2.'. :', 




25.6 




1025 


25.6 


25.7 






26.1 


26.2 








- 


1026 


26.7 


26.8 


" 


27.1 


27.2 


27.3 


27.4 








1"27 


27.7 


27.8 


28.0 


28.1 


28.2 


28.3 


28.4 






28.9 


1028 






29.0 


29.1 


29.2 


29.4 


29.5 


29.7 


29.8 




1029 




29 9 


30.1 


3o.2 


30.3 


1 


30.5 


30.7 




31.0 


1030 


30.8 


30.9 


31.1 


31.2 


31.3 


31 £ 


31.6 


31.8 


31.9 


32 1 


1031 


31.8 


32.0 




32.2 






32.6 


32.8 


33.0 


33.1 


1032 


32.9 


33.0 


33.2 


33.3 


33.4 


33.6 


33.7 


33.9 


34.0 




1033 


33.9 


r:4.0 


34.2 


34 3 




84.fi 


34.7 


34.9 


35.1 


35.3 


1034 


34.9 


K5.0 


I 


35.3 


35.5 


35.6 




36.0 


36.1 


36.3 


1035 


35.9 


36.1 


36.2 


36.4 


36.5 


36.7 


36.8 


37.0 


37.2 


37.3 



580 



THE SECRETION OF THE MAMMARY GLANDS. 



Estimation of the Fat. 

The estimation of the fat is most conveniently made by means of 
the lactoscope of Feser, shown in Fig. 138. Milk is drawn into 

Fig. 138. 




Feser's lactoscope. 



the pipette up to the mark M, when it is emptied into the cylinder 
C. The pipette is then rinsed with water and the washings added 
to the milk. While shaking, water is added until the black lines 
upon the milk-colored glass plug A can just be discerned. The fig- 
ure upon the right of the scale at the level reached by the mixture 
indicates the percentage-amount of fat, while the number upon the 
left indicates in cubic centimeters the amount of water that has 
been added. 

Estimation of the Proteids. 

Woodward's Method. — Two " milk-burettes " (see Fig. 139), 
each containing 5 c.c. of milk, are kept at a temperature of from 37° 
to 40° C. for from eighteen to twentv-four hours. At the end of 



THE MILK IS DISEASE. 



581 



this time the milk has separated into two layers, viz., an upper layer 
of viscid yellow tat, and a lower layer of fluid milk, which is quite 
opaque above and almost translucent below. Clinging to the sides 
of the tube, and especially at the bottom, a granular precipitate will 
be seen. The burettes are then cooled, when the milk-serum is 



Fig. 139. 




Woodward's milk-burette. 



withdrawn into two tubes graduated to 15 c.c, and treated with 
Esbach's reagent to the 15 c.c. mark. The mixture in each tube is 
thoroughly stirred with a glass rod and then centrifugated to a con- 
stant reading. 

Woodward ■ has checked his analyses by KjeldahPs method, and 
has obtained satisfactory results. 



1 G. Woodward. ,: A Clinical Method for the Estimation of Breast-milk 
Phila. Med. Jour., 1898, p. 956. 



'roteids. 



i x i ) i-: x . 



ABORTION, vaginal discharge in, 572 
Abscess of the liver with perfora- 
tion into the Lung, 295 
pulmonary, 29 1 

Absorption, rate of, in the stomach, 204 
Acetic acid, 191, 218 

fermentation, 191 
tests For, 191, 218 
Acetonemia, 58 
Acetone in the blood, " s 

in the gastric contents. 195 

in the urine, 4M 

quantitative estimation of, 4^7 

tests tor, 186 
Acetonuria, oS, 4^4 
Acholic stools, 223 
Achiroodextrin, 139, 180 
Acid, acetic. 191, 218 

benzoic, 386 

butyric, 191, 21S 

carbolic, 216, 483 

di acetic, 489 

(iiazo-benzene-sulphonic, 4^0 

glucuronic, 454 

hippnric, 385 

homogentisinic, 476 

hydrochloric, 155 

lactic, 183, 490 

oxalic, 392 

oxalnric, 392 

oxybutyric, 490 

phosphoric, 325 

propionic, 21 S 

succinic, 557 

sulphuric. .".:'» 1 

tauro-carbaminic, 341 

uric, 370 

uroleucinic, 47<> 

valerianic, 21 S 
Adds, organic, in the gastric contents, 183 
Actinomyces bominis, 289, 54] 
Actinomycosis, 289, 5 1 1 
Adenio in the urine, 371, 383 
Agglutinins, 117 
o-granulation of Ehrlich, 75 
Albumin, aceto-soluble, 409, 122 

in the feces, 261 

in the gastric contents 

in the urine, 398 

quantitative estimation of. 122 

special test for serum-albumin, 121 
for serum-ylobulin, 424 



Albumin, tots for, 415 

boiling, 419 

nitric- acid, lit) 

picric acid. 121 

potassium ferrocyanide, 420 

Spiegler's, 1-1 

trichloracetic acid, 420 
Albuminimeter, 423 
Albuminuria, 398 
accidental, 408 
colliquative, 404 
cyclic, 399 
Da Costa's, 399 
digestive, 407 
febrile, 402 
functional, 399, 401 
hematogenous, 401, 406 
in organic diseases of the kidneys, 

401, 411 
intermittent, 399 
mixed, 408 
neurotic, 407 
orthostatic, 399 
physiological, 398 
postural, 399 

referable to circulatory disturbances, 
4i)5 

to impeded outflow of urine, 1 >~> 
renal, 401, 408 
toxic, 406 
transitory, 399 
Albumoses in the blood, 18 
in the feces, 261 
in the gastric contents, 179 
in the urine, 409 
tests for, 182, 425 
Albumosuria, 109 

-live, 410 

enterogeuic, 109 

hematogenic, 1"0 

hepatogenic, 409 

histogenic, I"'.' 

pyogenic 109 

renal, 409 

vesical, I' 9 
Alkalimeter, Engel's, 2 1 
Alkaline stools, 210. 222 

in inc. .".1 1 
Alkalinity of the blood, 20 
distribution of, I'M 
estimation of, 21 

Alkapton in the urine-. '7~> 

5S3 



584 



IXDEX. 



Alkaptonuria, 475 

Alloxur bases in the urine. 371. I - 1 

estimation of. SM 
Almen's solution, 440 
Alreolar epithelium. 279 
Ammonia in the blood, 53 

in the gastric contents, 194 
in the urii e : . r 

estimation of, 369 
Ammoniacal fermentation, 312 
Ammoniaemia. 53 

Ammonio-magnesium phosphate, 504 
Ammonium urate. 513 
Amoeba coli, 233 

in the feces, 233 

in ihe sputum, 283 
Amoebae in the urine. 543 
Amoebic colitis, 233 
Ainoebinse in feces. 233 
Ampliistomum hominis 247 
Amphoteric urine, 311 
Amyloid corpuscles in the semen, 566 
AnacHorhydria, 162 
Anacidity, hysterical, 163 
Anadeny of the - _ 1 . 

Anaemic degener. :. . r .: :'z- :-! 

cles, 63 
Anchylostomiasis. 249 
Anchvlostomum duodenale, 249 
Anguillula intestinalis, _ " 1 

--. : oralis, 251 
Anguilluliasis, 137, 251 
Anilin dyes, classification of 

water, gen tian-T. '_-■ 1-. 
Animal gum in the urine. 454 
Animal parasites in the blood. 125 

in the feces, 231 

in the sputum. 1 : 1 

in the urine. 542 
Annelides, 247 
Anthomyia, 232 
Anthra.cosis of the lung- _ 
Anthrax, bacillus of, 121 
Arnold's test for acetone, Hi I 
Aronsohn-Philips stain 100 
Asearides ir - e feces 247 

in the urine. 543 
Ascaris lumbricoides 247 
— 'TV. :z L- ; 
mjsfax 84S 
Asiatic cholera, bacillus of 252 

feces in. 1 
Asthma, bronchial. Chareot-Levden erys- 

tals in. 2 -. 
A : -pennatisn- 



Baallns of anthiax, 121 

: : :_ :'.i:\, .-.-:;.:_.: i: 1 
:: ;- -_r:_;. \-,\ 
of dvsmterr, 25© 

: Y-sli: rrl Ir:.: _:i 
. : ^Irrirrs 1__ 
:: Irrr-rr-r '-— _r: 
:: >ir;>s-r. _-' 
: : - -..-'. 
.: Malta fever, 12-4 
: - :".r: izi 1- r- i.l 
.: :-:Ver: rliL-is ::. :r- ;"...:.: Ill 
ir. ;1.t :'e:-es 25: 
ir :r-e rz-eririrei. r. i: :■." . 
in the milk, 57 8 

ir ::: rrsr". :.-:!.. :rr 2:~ 



:: :y; :. ::: :- r: 

ir z - :- : 
ir :_t .:: 

::' •-"_. :•:; irg-o: :.g 
: Jc-i ~ :T _ r: 1 _- 

rjxyirrr.? _ r ~ 



I.::- 



ir. :"_:■:•: 11: 
553 



: i 



B 



ACTLLI of Booker. 253 
Bacillus acidophilic . ' " 

" -7-ri: - 211 
:•:!: •:• :::: : - _'- : 
-- - :- _• 

- _ " 
melitensis, 124 



ir m'.k ~~~ ':' -. 
in month, 140 
ir r -:'_ seir-E-:: r 1." 
in pos, 553 
: z i ". ' zz _ " : 
:r f:::r : :" 
ir _ : . : r r " 
3 - :r;.:l ie:-:r_p:>si:; :r : :' :l.e 
■ i 

Mi :: : ::.: : Ml 
2 .;. ::f:. :rr !::'..:-: 1: ^:-- 2 r ~ 
Mi:r::Mr_ :•:!: 2-: ^ 
I-rrr ; :es: :':: :'- .zzz -•■---• 42: 

:'.:v::' M : r - _ : 
rrrMM - r-r^er: 1 M 
Basic anilin dyes, 71 (foot-note) 
double stain, 102 

phosphate of magnesium, 505, 513 
Basophilic leucocytes in the blood, 76 
ir :z- r. ~; r. L' - * 
perinndear grannie- 
I ;.:":- z ::' _ i~ :.z: r-rky'? r_e:r :■: : 

.-:". •".::" r :.:::::> - '. 
I-rr :-t ': V :1 - ::. ir 411 
:efi- :' : 42" 
It-.::: : ::: ir :'zr 'rr :■.:" 
BenBopnipniin test for fevdroehlorie acid, 

11:' 
r:i--: irr ::; ir •':.: V. •:•: 
ir :: t :-:-f- L.'l 
ir r.T ^:. ?:r: : :• :r:fr> '. * 



INDEX. 



Bile-pigment in the urine, 469 
tests for, 470 

Gmelin's, 471 
Buppert's, 470 
Rosenbach's, 471 
Smith's, 47D 
Bilharzia heematobia, 136 
Bilharziasis, 136 
Biliary acids in the blood, 57 
in the feces. 219 
in the urine, 471 
tests for, 57, 220 

concretions, 227 

analysis of. 228 
Bilirubin, 57, 469, 512 
Biuret test, 352 
Blood, 17 

acetone in. ">^ 

albumins in. 26, 48 

albumoses in, 48 

alkalinity of, 20 

ammonia in, 53 

bacteriology of, 113 

biliary constituents in, 57 

carbohydrates in, 49 

cellulose in, 52 

chemical examination of, 24 

coagulation of, 26 

color of, 17 

color-index, 34 

drying and staining of, 96 

fat in, 28. -V) 

fatty acids in, 55 

fibrin in, 26, 48 

gases in, 28 

general characteristics of, 17 
chemistry of, 25 

glycogen in, 51 

haemokonia of, 105 

in the feces, 223, 230 

in the gastric contents, 198 

in the sputum, 27], 278 

in the urine, 413, 522 

lactic acid in, 55 

leucocytes of, 17, 69 

medico-legal tot for, 44 

microscopical examination of, 58 

nucleated corpuscles in, 67 

odor of, L8 

parasites in. 1 13 

parasitology of, 113 

peptone in, I s 

pigments of. 20 

proteida in. 17 

protozoa in, 125 

reaction of, 20 

solids of, 20 

specific gravity of, 18 

Btaining of, 96 

BUgar in, 49 

tests for, 44, 198 

Donogany's, 199 
guaiacum, 429 



Blood, tests tor. Heller's, 129 

Korczynski and Jaworski's, 221 
Mullerand Weber's, 198 

urea in. 52, 
uric acid in, 53 
xanthin-bases in, 53, 55 

Blood-corpuscles, red, 58 

anaemic degeneration, of, 63 

behavior toward anilin dyes, ti.'i 
granular degeneration of, 65 
enumeration of, 106 
nucleated, 67 
variations in color, 62 
in form, 59 
in number, 60 
in size, 58 
white (see Leucocytes). 
Blood-crisis, 67 
Blood-iron, 36 
Blood-plasma, 17, 24, 27 
Blood-plates, 104 
Blood-serum, 24, 26, 27 
Blood-shadows, 523 
Boas' bulbed stomach-tube, 151 

method for estimating lactic acid, 188 
test for hydrochloric acid, 165 
for lactic acid, 187 
Boas-Oppler bacillus, 201 
Bodo urinarius, 542 
Bothriocephalus latus, 243 
Boucher's crystals, 291, 565 
Bbttger's test for sugar, 440 
Bremer's diabetic blood test, 64 

urine test, 451 
Brodie and Russell's method of enumerat- 
ing the plaques, 110 
Bronchial asthma, 275, 293 
Bronchitis, acute, 293 
chronic, 293 
fibrinous, 293 
putrid, 293 
Browning's sped roscope, 47 
Buccal secretion (see Saliva), 138 
Butyric acid fermentation, l'.'l 
in the feces, 218 
in the gastric contents, 191 
tesl for, 191 

CAI>A\'i:mx. 262, 341, 195 
Cahn-Mehring's method of estimat- 
ing fatty acids. 192 
Calcium carbonate, crystalsof, 5] 1 

oxalate, crystals of. 292, 503 

phosphate, crystala of, 505 

sulphate, crystala of, 506 
Calliphora erythrocephala, 232 
Calomel stools, 208 
Carbohydrates, digestion of, 179 

in the blood, I!) 
in the feces, 261 
in the urine, 430 
testa to.-, 438 
Carbol-fuchsin, 286 



m 



IXDEX. 



Carbolic acid, estimation of, 483 

test for, 216. 463 
Carbolo-chloride of iron test for lactic 

acid, 185 
Carbon dioxide haemoglobin. 42 

monoxide haemoglobin, 41 
Caries of the teeth, 188 
Casein, digestion of, 179 
in the milk. 577 
test for, Leiner's, 229 
Casts, classification of, 525 
examination of, 526 
fatty, 529 
fibrinous, 273 
formation of. 531 
granular. 527 
hyaline, 526 
pus. 527 

significance of, 532 
staining of, 526 
urinary, 525 
waxy, 529 
Catarrh, acute intestinal, 262 
bronchial, 298 
chronic intestinal, 263 
duodenal, 262 
intestinal, of infants, 263 
of ileum, 262 
of jejunum, 262 
of large intestine. 262 
Cause's method of estimating sugar, 445 
Cellulose in the blood, 52 
Cenomonadina, 235 
Cercomonas intestinalis. 236 
Cerebrospinal fluid, 558 
amount of, 559 
appearance of, 559 
chemical composition of, 561 
microscopical examination of. 

562 
reaction of, 561 
specific gravity of. 560 
Cestodes. 232 
Chalicosis, 297 

Charcot-Leyden crystal, in the feces, 231 
in the nasal discharge, 268 
in the sputum, 275, 276. 290 
Chemical examination of blood, 24 
of cvstic fluids. 555 
of feces. 214, 260 
of gastric juice, 154 
of milk. 576 
of pus. 551 
of saliva, 138 
of semen, 564 
of sputum, 292 
of transudates. -547 
of urine, 315 
Chenzinsky-Plehn's stain, 101 
Chlorides in the urine, 317 
estimation of, 320 

according to Xeubauer and 
Salkowski, 325 



Chlorides in the urine, estimation of, ac- 
cording to Salkowski and 
Vol hard, 320 
direct method, 324 
test for, 320 
Chloroform-benzol mixture. 19 
Chokernia, 57 
Cholera Asiatica, 265 

bacillus of, 252 

infantum, 263 

nostras, 263 

bacillus of, 253 
Cholesterin in the blood, 28 

in the feces, 218 

in the sputum, 292 

in the urine, 471 

isolation of, from the feces. 21 S 

test for. 219 
Choluria, 469 
Chorion villi. 578 
Chromosrens in the urine. 455 
Chyluria, 136. 414, 492, 513 
Chymosin. 176 

estimation of, 178 

test for, 17S 
Chymosinogen, 176 

estimation of, 178 

test for, 178 
Ciliated epithelium in cysts, 555 

in the sputum, 279 
Cladothrix. 2-9 
Coagulation of the blood, 26 
Coating of the tongue, 144 
Coccidia in the feces. 239 
Coffin-lid crystals. 504. 514 
Colica mucosa. 226 

Colloid concretions in ovarian cysts, 556 
Color index of the blood. 34 
Colostrum, 575 
Comma bacillus. 252 
Concretions, biliarv, 227 

fecal, 22S 

intestinal, 228 

pulmonary, 277 
Congo-red test for free acids, 163 
Conjugate glucuronates, 454 

sulphates, 33tf. 483 
Copper test for uric acid, 377 
Coproliths, 228 
Corpora amylacea, 566 
Cresol in the feces. 217 

in the urine, 4S3 
Crystals. ammonio-magnesium phos- 
phate, 501. 514 

bilirubin, 512 

calcium carbonate, 514 
oxalate, 292. 502 
phosphate, 504, 505, 513 
sulphate, 506 

Charcot-Levden, 212, 231. 275. 276, 
290 

cholesterio, 212, 292, 471 

cystin, 507 



INDEX. 



587 



Crystals, tatty acids, 210, --".'-J 

bsematoidin, 45, 291, 512 

haemin, 43 

hippuric arid. 506 

indigo, 2 10. 231, 290, 5] I 

leucin, 508 

leucocytic, 291 

magnesium phosphate, 505,513 

monocalcium phosphate, 505 

neutral calcium phosphate, 506 

phenyl-glucosazon, 441 

phosphate oi spermin, 564 

xeichmann, 4 1 

triple phosphate, 292, 504, 514 

tyrosin, 292, 

urate of ammonium, 513 

nric acid, 500 

xanthin. oil 
Curschmann's spirals, 275 
Cylinders, mucous, in the feces, 226 
in the urine, 531 

urinary, 525 
Cylindroids, 525, 531 
Cylindruria, 52-5 
C^stein, 340, 341 
Cysticercus eellusos;e, 242 
Cystin, 341. 507 
Cystinuria, 341, 507 
illoid, 556 

contents of, 555 

dermoid. 556 

fibro-cystic, 556 

hydatid. 557 

ovarian, 557 

pancreatic, 557 

parovarian, 556 

D ALAND'S hamatokrit, 111 
Decidual cells, 574 
^-granulation of Ehrlich, 76 
Dennige's te-t for acetone, 58, 486 
I dermoid cyst-. 556 
Dextrin in the urine. 452 
I textrose in the urine ae • ( rlu< 
tea, 436 
alternans, 375 
Bremer's blood test in, 63 

urin ■ test in, I'd 
elimination of sugar in, 136 

of urea in, 3 19 

hepatogenic, 137 
Birschfeld's form of, 349, 138 
insipidus, 304, 320 
myogenic, 437 
phosphatu 

Williamson's Mood test in. : ' ,) 
Diacetic acid in the urine. 189 

Diaceturia, 489 
Diamins in the feces, 262 
in the urine, 341, 495 
isolation oi 
Diarrhoea of infant-. 263 



Diathesis, oxalic acid, 39 I 

uric acid, 374 
1 tiaso-reaction (see Ehrlich' s read ion), l i 9 
Digestion, gastric, 178 

of albumins, 178 

of albuminoids, 170 

of carbohydrates, 179 

of milk, 179 

of proteids, 17:' 

products of, 183 

Dimethyl-amido-azo-benzol test, I'll 
1 >iphtheria, 1 l"> 

Diplococcus meningitidis intracellularis, 
562 

pneumoniae 1 19, 287 
in the blood, 118 
Distoma Buskii, 246 

capense, 136 

conjunctum, 247 

haematobium, 1:56, 283, 543 

hepaticum, 245 

heterophyes, 217 

lanceolatum, 246 

pulmonale, 283 

rbatonisi, 246 

sibiricum, 246 

spatulatum, 217 
Distomiasis, 136 
Donne's pus test, 519 
Donooany's blood test. 109, 430 
Doremus' ureometer, 357 
Drosophila melanogastra, 232 

DrilgS, etleet of. on the Color of tie 

208 
Drysdale's corpuscles, 
Dunlop's method of estimating oxalic 

acid, 396 
Du>t-partieles of Midler, 105 
Dysentery, 26 1 
amoebic, 26 1 
Shiga's bacillus of, 259 

EM; Id IV phosphates, 328 
Eberth's bacillus, 254 
Echinococcus, 276, 28 1 

membranes in the sputum, 276 
polymorph us, 282 
e-granulation of Ehrlich, 7.') 
Ehrlich' s granulations, 7 I 
hsematoxylin-eosin, 101 

neutral red, '< 10 

neutr.d stain, 102 

reaction, 170 

tri-acid stain, 100 

tri-glycerin mixture, 102 
Ein horn's bucket, 1">"> 
barimeter, 1 17 
Elastic tissue in the sputum, 273, 280 

-tain for, 281 
Eisner's method, 256 
Engel's alkalimeter, 2 I 

method of estimating the alkalinity 

of the 14 1. \1\ 



588 



INDEX. 



Enteritis, acute, 262 
chronic, 263 
membranous, 226, 263 
mucous (see Membranous), 226, 263 
Enterogenic albumosuria, 409 
Enteroliths, 228 
Eosin, staining with, 102 
Eosin-methylal and methylene-blue, 103 
Eosinate of methvlene-blue, staining with, 

99 
Eosinophilia, 89 

Eosinophilic leucocvtes in the blood, 
75, 79 
in the sputum, 275, 277 
Epithelial cells, alveolar, 279 
ciliated, 279 

in the buccal secretion, 140 
in the feces, 230 
in the gastric contents, 201 
in the sputum, 278 
in the urine, 515 
in the vaginal secretions, 569 
Eructatio nervosa, 195 
Ervthrodextrin, 139, 182 

* test for, 139, 182 
Erythrosin, acid, staining with, 104 
Esbach's albuminimeter, 423 

method of estimating albumin, 423 
reagent, 423 
Escherich's stain. 258 
Ethyl sulphide, 341 
Euchlorhydria, 162 
Eustrongylus gigas, 543 
Ewald's modification of Mohr's test for 

hydrochloric acid, 166 
Extractives in the blood, 28 
Exudates, 545, 548 
chyloid, 554 
chylous, 554 
hemorrhagic, 549 
in cancer, 549 
in tuberculosis, 549 
purulent (see Pus), 550 
putrid, 550 
serous, 548 

FAT in the blood, 28, 55 
in the milk, estimation of, 580 
in the urine, 492, 512 
Fatty acids, clinical significance of, 190 
estimation of, 192 
formation of, 190 
in pus, 554 
in the blood, 55 
in the feces, 217 
in the gastric contents, 190 
in the sputum, 292 
in the urine, 491 
tests for, 191, 218 
Fatty casts, 529 
Febrile acetonuria, 484 
albuminuria, 402 
urobilin, 220, 455, 473 



Fecal matter in the urine, 543 

vomiting, 199 
Feces, 207 

alimentarv detritus in, 208, 225 

amount of, 207, 222 

annelides in, 247 

biliary acids in, 219 
concretions in, 227 

blood in, 230 

chemistry of, 214, 260 

cholesterin in, 218 

color of, 208, 222 

composition of, 210 

concretions in, 227 

consistence of, 207, 222 

crystals in, 210, 231 

examination of normal, 207 

fattv acids in, 217 

flagellata in, 235 

foreign bodies in, 209 

form of, 207, 222 

gases in, 215 

general characteristics of, 207, 221 

indol in, 216 

insects in, 251 

macroscopical constituents of, 208 

microscopical constituents of, 209, 
228 

mucus in, 226, 230 

number of stools, 207, 221 

odor of, 208, 222 

parasites in, 212 
animal, 231 
vegetable, 212,251 

pathology of, 221 

phenol in, 216 

pigments in, 220 

protozoa in, 232 

ptomains in, 262 

reaction of, 210, 222 

skatol in, 216 

technique in examination of, 228 

trematodes in, 245 

vermes in, 239 
Fehling's method of estimating sugar, 444 

solution, 439 

test for sugar, 439 
Ferment, milk-curdling, 176 

of saliva, 139 
Fermentation test for sugar, 440 
Ferments in the gastric juice, 173 
Ferrometer, Jolles', 36 
Feser's lactoscope, 580 
Fibrin, 26, 48 

estimation of, 48 

ferment, 26 

in the blood, 26 

in the urine, 414 

test for, 430 
Fibrinogen, 26 
Fibrinoglobulin, 26 
Fibrinous casts, 273 

coagula in the sputum, 273 



INDEX, 



589 



Fibrinous coagula in the urine (see Chy- 

Luria ). 
Pilaris Bancrofti, 135 
diurna, 135 
Mansoni, 135 
nocturna, 135 
perstans, 135 

sanguinis hominis, 135, 543 
Wuchereri, 135 
Filariasis, 135 
Finkler-l'rior bacillus, 253 
Flagellata, 235 
Fleischl's hssmometer, 32 
Florence's test for semen, 5 17 
Folin's method of estimating ammonia, 
370 
urea. 363 
uric acid, 378 
Foreign bodies in the feces, 209 
in the sputum, 277 
in the urine, 543 
Formic arid, detection of, 218 
Frennd's method of determining acidity 

of urine, 314 
Furfural test for bile acids, 220 
Futcher's stain, 12(3 

GABETTS staining method. 230 
Galacturia, 492 
Gall-stones in the feces, 227 

analysis of. L'27 
(rangrene of the lung, 294 
Garrod's tot for haematoporphyrin in the 
nrine. 468 
for honiogentisinic acid, 477 
for uric acid in the blood, 55 
Gases in the blood, 28 
in the feci--, 215 
in the gastric contents, 193 
in the urine, 493 

Lc contents, examination of (see also 
. 143 
<iastric digestion of albuminoids, 179 
of carbohydrates, 179 
of native albumins, 17s 
of proteins, 179 
prod 

analysis of, 1 81 
< rastric juice, 1 18 

acetic acid in, 192 

ue in, 195 
acidity of, 155 
amount of, 1",:; 
antiseptic properties of. Ml 
aspiration of. 152 
blood in. 198 
butyric acid in. 191 
cause of acidity of. 155 
chemical composition of. 15 1 

examination of, 154 
chymosin in, 17G 
chymosinogen in. 176 
expre^ion >■(. 152 



Gastric juice, fatty acids in, 190 
ferments in, I 

free acid in, 155, 163 
^:i>e> in, 193 

general characteristics of, 1 •">■'. 

hydrochloric acid in, 155, 100 

hyperacidity of, 159 
hypersecretion of. 15 I, I 
indirect examination of, 205 

lactic acid in, 183 
methods of obtaining, 151 
microscopical examination of, 

200 
milk-curdling ferment of, 170 
organic acids in, 190 
pepsin in. 175 
pepsinogen in. 175 
ptomaine ami toxalbumins in, 195 
secret ion of. I 
zymogens in, 173 
Gastrosucorrluea mucosa, 197 
Gigantoblasts (see Megaloblasts), 68 
(■landers, bacillus of, 122 
Glandular fever, 145 
Glucose, 430 

in the blood. 49 

estimation of, 50 
in tin- urine, 430 
Xylandeivs test for, 4-10 
quantitative estimation of, 444 

tests for, 138 
Glucosuria, 430 
digestive, -151 

liaro, 434 

ex amylo. -i:U 

persistent, 43 '■ 

transitory, 434 
Glucosuric acid, -170 
Glucuronic acid in the blood. 49 
* rlycogen in the blood, 51 
test for. 52 

in the sputum. 29:1 

in the urine. 45 1 
Gmelin'fl reaction. 171 

( ronococcus in the blood, 120 

in the month. 1 13 

in urethral discharge, 5 10 

of Neisser, 5 1" 

staining of. 540 
Gonorrhoea] Btomatitis, 143 

threads in the nrine, 541, 5 !.", 
(rowers' hsemoglobinometei 

< tram's method of staining, 146 
( Iranular degeneration, 65 
y-granulation of Ehrlich, 7''. 

( i rape-sii^rr I Bee ' rllli 

< rreen's ureometei 

Grethe's method nf staining tubercle ba- 
cilli in the urine. 
Guaiacum test for blood, 129 

< ruanitl in the nrine, :;7 1. 

< lam, animal, 15 1 



590 



INDEX. 



Gunning's mixture, 364 
Giinzourg's packages, 205 

reagent. 164 
Gynaecophorus, 136 

H.EMATEMESIS, 198 
Hsmatiu. 43 
H^matinuria. 466 
Haematoblasts, 104 

Harmatoidin in the blood, 45 

in the sputum. 291 

in the urir.e. 152 
Haematokrit, 110 
llsematop^rphyrin in the blood. 45 

in the feces, 221 

in the urine. -: S 
Ha?matoporpbyrinuria. 46. - : 
Hematuria. 413. 522 
Hsemin sec Teichmann's crystals . 43 
HaE-moeytoroeter of Thoma-Zeiss. 105 
Haemoglobin, 17. 29 

carbon dioxide. 42 
monoxide. 41 

estimation of. with Fleisehl's haemom- 
eter. i '2 
with Gowers* harmoglobinome- 
ter. 35 

hydrogen sulphide, 42 

nitric oxide, 42 

tests for. 44. 198 
Ha?moglobinieinia. 40 
H:-rnoglobinometer of Gowers. 35 
Hcemosrlobinuria. 41. 412 
Ehernokonh 1 .. 10a 
Hsemometer ofFleischl, 32 
Hemospermia. 566 
Halitus sanguinis. IS 
Hammerschlag's method, 19 
Havcraft's method of estimating; nric acid. 

379 
Hayem's fluid, 106 
He: rr-disease cells. 296 
Hehner-Seemann'- method of estimating 

organic acids. 192 
Heller's test for albumin, 416 

i : 42 

Hepatogenic icterus. 469 
Heteroxanthin in the urine. 371. 383 
Hippuric acid in the urine. 385, 506 
estimation of. 387 
properties of, 386 
test for, 387 
Histon in the urine, 415 

tes: 
Hoftmanus test for tyrosin, 510 
Hofmeister's method of estimating hip- 
puric acid, 388 
test for leucin. 510 
Homialomyia. 232 
Homogentisinic acid in the urine. 476 

i-'olation of, 477 
Hopkins' method of estimating uric acid. 



H tuner's ureometer. 361 
Hnppertfs test for bile-pigment. 470 
Hydatid cysts. 557 

echinococcus membranes and 

booklets in. 557 
sodium chloride in. 557 
succinic acid in. 557 
Hydrobilirubin. 220 
Hydrocele fluid. 547 

cholesterin in. 547 
Hydrochinon in the urine, 475 
Hydrochloric acid in the gastric juice. 155 
amount of. 162 
combined. 167 
estimation of. according 
to Leo. 172 
according to Mar- 
tins and Liittke. 
170 
according to Top- 
fer. 168 
free. 155 
quantitative estimation 

of. 168 
s ^nificance of, 160 
source of. 159 
tests for, 164 
Hvdroscn sulphide, in the gastric con- 
tents. 194 
tests for, 194 
in the urine.. 494 
Hydronephrosis, 557 
Hydrothionuria, 342. 493. 507 
Hypaltuminosis. 48 
Hyperalbuminosis, 45 
Hyperchlorhydria. 163 
Hyperinosis. 48 
Hy peri sot onia, 28 
Hyperleucocytosis SO 
live, 80 
mixed. 91 
passive, -0, 93 
pathological. 84 
physiological. 81 
polynucl philic, 89 

neutrophilic. 81 
Hypersecretio acida et continua. 154, 163 
Hypersecretion. 154 
Hypinosis, 4 > * 

Hyj jhromite method of estimating area, 
355 
solution. 355 
Hypochlorhydria. 162 
Hypoleucocv: osis, 80, 94 
Hypoxanthin in the urine. 371. 383 

ICTERUS, 469 

JL hieinatogenic. 470 

hepatogenic. 469 

neonatorum. 470 

urobilin. 473 
Idiopathic bacteriuria. 541 

oxaluria. 394 



INDEX. 



591 



[lasvay's reagent, 1 W 
[ndican in the urine, 158 
estimation of, 4(32 
tests for, 401 
Indicanuria, 158 

[ndigo-blue in the urine, 461, 480, ol4 
[ndigo-red in the urine, 404 
[ndigosuria, 161, 480 
Indol in the Fee s, 216 
tests for, 216 
[ndoxyl, 4-3S 

Bulphate isee [ndican ), 458 
[nfiuenza, bacillus of, 122, 288 
[nfusoria in pus. 553 

in the feces, 231 

in the urine. 5 13 

in vagina] discharges, 570 
luosit in the urine, 455 
Insects in the feces. 251 
Intermittent albuminuria, 399 
Intestinal catarrh, 262 

concretions, 227 

putrefaction. 261, 458 
Intestines, diseases of, 262 
Iodine stain for the Plasmodium malarias, 

127 
Iodoform-test for lactic acid, ISO 
[odospermin, 567 
Iron test, 224 

in blood, 30 
Isotonia, 27 

JAFFF'S test for i ndican, 461 
Jaundice (see Icterus), 469 
Jenner's stain, 99 
Jolles' ferrometer, 36 

[TELLING'S test for lactic acid, 186 

JV Kjeldahl's method, 364 

Knap p' s method of estimating sugar, 446 

Koplik's bacillus, 288 

Korczynski and Jaworski's test, 224 

Krahbea grandis, 24") 

Ivrr.it in, ■ 

property - 

Kreatinin. 

estimation of. 390 

properties of, 389 
test for, 390 

Krealinin-zinc chloride, 3 

LACMOID paper, preparation of, 25 
Lactic acid, I 83 

bacillus of, 183 

clinical significance of, 
imation of, 1 " x 

fermentation, l v o 
in the blood, 56 
in the gastric content-. 183 
in the urine. 

mode of formation. I 33, 1 85 
te-t.- for, 1 x "» 
Boas', 186 



Lactic acid, tests for, Spelling's, 185 

Strauss', 185 

Uffelmann's, 185 
Lactodensimeter of Quevenne, : >7"> 
Lactoscope of Feser, 580 
Lactose in the urine, 452 
Laiose in the urine, 453 
Landois' estimation of the alkalinity of 

the blood, 21 
Laveran's organism, 125 
Laverania malaria?, l.'il 
Lecithin in the blood, 28 
Legal's test for acetone, 186 
Leiner's test for casein, 229 
Leo's method of estimating hydrochloric 

acid, 172 
Leprosy, bacillus of. 285 
Leptothriz buccalis, 1 1"> 

pulmonalis, 29 I 
Leube's test of motor power of stomach, 

204 
Leucin, 508 
Leucocytes, 17, 00 

basophilic, 70 

degenerative changes, 74 

differential enumeration, 110 

differentiation according to their be- 
havior toward anilin dyes. 71 

Fhrlich's granulations in, 71 

enumeration of, 108 

eosinophilic, 75, 79 

estimation of the number of, 108 

general differentiation of the various 
forms, 69 

indirect enumeration of, 109 

in the blood, 17. 69 

in the exudates, 5 18, 551 

in the feces, 231 

in the sputum, 277 

in the urine, 51 s 

irritation forms, 70 

large mononuclear, 73 

lymphogenic, 7 1 

myelogenic, 78 

neutrophilic, 7"». 78 

oxyphilic, 75 

polymorphonuclear, 7:) 

polynuclear, 7:; 

paeudolymphocytes, 79 

small mononuclear. 71 

transition forms. 7.". 

variations in number of 
Leucocytic crystals, 291 
Leucocytosis (see Hyperleucocytoais . 30 

active, vl » 

digestive form of. s] 

passive, 80 
Leucopenia, '.' 1 
Leukemia, lymphatic, 9 1 

myelogenous, '.'I 
Levulose in the urine, 152 
Lieben's tesl lor acetone, 486 
Lientery, 225 



592 



INDEX. 



Lipacida?mia, 56 
Lipaciduria, 491 
Lipaemia, 56 

Lipuria, 491, 512 
Lithsernia, 53 
Liver, abscess, 295 

acute yellow atrophy of, 508 
diseases of, feces in (see Acholic 
stools). 
urine in (see Bile-pigments). 
Lochia, 571 
alba, 571 
rubra, 571 
Loffler's bacillus, 145 

methylene-blue solution, 146 
Lohnstein's saccharimeter, 448 
Lowv's method of estimating the alka- 
linity of the blood, 23 
Ludwig-Salkowski's method of estimating 

uric acid, 381 
Lymphocytes, 72 
Lymphocytosis, 93 

MACEOCYTES, 59 
Maerocythaernia, 59 

Magnesia mixture, 331 

soaps of, in the urine, 512 

Magnesium phosphate. 505, 513 

Malaria, plasmodium of, 125 

Malta fever, bacillus of, 124 

Maltose in the urine, 452 

Mammary secretion, 575 

Marrow cells, 78 

Marshall's ureometer, 361 

Marsh gas in the gastric contents, 193 

Martins and Liittke's method of esti- 
mating hydrochloric acid, 170 

Masons' lun.s: (see Siderosis), 297 

Mastzellen, 76 

Meconium, 265 

Medico-legal test for blood, 43 

Megaloblasts. 6S 

Megalocytes, 59 

Megastoma entericum, 237 

Mel anaemia, 134 474 

Melanin in the urine. 474 
tests for, 475 

Melanogen, 474 

Membranous dysmenorrhea, vaginal dis- 
charge in. 572 

Meningeal fluid, examination of, 558 

Menstruation, vaginal discharge in, 571 

Metalbnmin in ovarian cysts, 555 

Methaemoglobin, 45 
sulphide, 42 

Methemoglobinemia, 41, 45 

Methaemoglobinaria, 41 2 

Methane see Marsh gas), 193 

Michael is' stain, 103 

Microblasts, 69 

Micrococci in pus, 553 

Micrococcus urea?, 537 

Microcytes, 59 



Microcythaemia, 59 
Micro-organisms in pus, 553 
in the feces, 213, 251 
in the milk, 577, 578 
in the mouth, 140 
in the nasal secretion, 267 
in the urine. 536 
in vaginal discharges, 570 
Microscopical examination of cystic fluids, 
555 
of exudates, 548, 551 
of the blood, 58 
of the buccal secretion, 140 
of the feces, 209 
of the gastric contents, 200 
of the nasal secretion, 267 
of the sputum, 277 
of the urine, 498 
of the vaginal secretion, 569 
of the vomit, 169, 200 
of transudates, 548 
Miescher's hsemometer, 34 
Milk, 575 

chemical composition of, 576 
cows', 577 

examination of, 578 
fat in, estimation of, 580 
human, 576 
in disease, 577 
proteids of, 580 

secretion of, in the adult female, 
576 
in the newly born, 575 
specific gravity of, 578 
witches', 575 
Milk-curdling ferment in the gastric 

juice, 176 
Millon's reagent, 425 
Mohr's test for hydrochloric acid, 166 
Monad in a in feces, 235 
Monera in the feces, 232 
Monocalcium phosphate, 505 
Moro's bacillus, 257 

Motor power of stomach, examination of, 
203 
Leube's method. 203 
salol test of Ewald and 
Sievers, 204 
Mouth, actinomycosis of, 143 
secretions of, 138 
tuberculosis of, 143 
Mucin in the feces, 260 
in the urine, 414 
test for, 428 
Mucous corpuscles in the urine, 299 
cylinders in the feces, 226 
in the urine, 531 
Mucus in the feces. 226, 230 

in the gastric contents, 197 
Muller- Weber test for blood, 198 
Murexid test. 377 
Myekemia. 92 
Myelin granules in the sputum, 279 



INDEX 



593 



Myelocytes, eosinophilic, 79 
neutrophilic, Ts 
of Cornil, 7s 
of Ehrlich, 78 

NASAL catarrh, 267 
secretion, 2u< 

cerebrospinal fluid in, "267 

characteristics of, 267 

Charcot - Leyden crystals in, 

286 
in disease, 267 
Neisser, gonococcus of, 540 
Nematodes, 232 
Nessler's reagent, 187 
Neubauer's method of estimating oxalic 

acid. 395 
Neusser's grannies, 77 

stain, 101 
Neutral phosphate of calcium in the 
urine, 505 
red stain for gonococci, 540 
sulphur in urine. 340 
Neutrophilic granules in the blood, 73, 

78 
Nitric acid test for albumin, 416 
Nitric oxide haemoglobin, 42 
Nitrites in the saliva. 139 
Nitrogen in the urine, 347 
estimation of, 364 

according to Kjeldahl, 364 
according to Will-Varren- 
trapp, 366 
Nitrogenous equilibrium, 347 
Nitro-prusside of sodium as a test for 

acetone see Legal's test), 486 
Nocht-Romanowsky stain, 126 
Normal urobilin, 455, 471 
Normoblasts, 67 
N a . secretion from, 2« >7 
Nubecula in the urine. 299 
Nucleated red corpuscles, 67 
Nucleo-albumin in the blood, 48 
in the urine, 414 
test for, 428 
Nucleohiston in the urine, 415 
Nummular sputum, 272 
Nv lander" s test for sugar, 440 

0BERM IYER'S reagent, 461 
Obermeier, spirochaeta of, 12:') 
is of the lungs, sputum in, 296 
Oidium albicans, 14 1, 290 
Olefiant gas, 194 
( Higochromsemia, 32 
( Migocythasmia, 32, '11 
( Oliguria, 305 

Orcin test for pentoses, 453 
Organic acids in the blood, 55 

in the gastric juice. 1 B3 

'quantitative estimation 
of, 192 
in the sputum, 290 



Organized sediments of the urine, 515 
I 'it s test, 128 

( >varian cysts, ; >.V) 

Oxalate of calcium crystals in the sputum, 
292 
in the urine, 502 
Oxalic acid, diathesis, 39 I 

in the urine, 392 

properties of, 394 

quantitative estimation of, 395 

tests tor, 395 
Oxaluria idiopathica, 394 
( (xaluric acid, 392 

Oxvbntyric acid, ■ :>, in the urine, 490 
Oxyhemoglobin, 18, 29 
Oxyuris vermicularis, 248 
Ozsena, 267 

PACINI'S fluid, 106 
Pancreatic cysts, 557 

trypsin in. 557 
juice in the gastric contents, 198 
Pappenheim's stain, 285 
Paraciesol in the urine, 483 
Paramecium coli, 239 
Parasites in the blood, 113 
in the feces, 212. 231 
in the gastric contents, 200 
in the sputum, 281 
in the urine, 536 
malarial, 113 
Paraxanthin in the urine. 371, 383 
Patein's albumin, 409, 122 

test for, 422 
Pathological acetonuria, 484 
albuminuria, 398 
glncosuria, 436 
urobilin, 471 
Pentoses in the urine, 453 

test- for, 453 
Pepsin in the gastric juice, 173 
estimation of, 176 
tests for, 175 
Pepsinogen in the gastric juice, 173 
estimation of, 176 

tests for. 17") 

Peptonuria (see Albumosuria ). 
Persistent glncosuria, 136 
Pettenkofer's test, 220 
Phagocytes, 69 
Phagocytosis, 69, 134 
Pharyngomycosis leptothrica, 146 
Phenol, 216, 475, 183 

estimation of, 483 

in the feces, 216 

in the urine, 475, 483 

tests fur. 216, 483 

Phenylglucosazon, 4 1 1 
Phenylhydrazin tesl for sugar, 411 
Phloroglucin test for pentoses, 153 

vanillin test for hvdrochloric acid, 
164 
Phosphates in the urine. 325. 504 *"■ 



594 



INDEX. 



Phosphates in the urine, estimation of. 331 
removal of, from urine, 334 
separate estimation of alkaline 

and earth v, 334 
tests for, 330 
Phosphatic diabetes, 328 

sediments in the urine, 504, 505, 513 
Phthisis pulmonalis. sputum in, 295 
Picric-acid test for albumin, 421 
Pigments in the feces, 220 

in the urine, 455 
Piorkowski's method, 254 
Piria's test for ty rosin, 510 
Placenta sanguinis, 25 
Plaques, 104 

enumeration of, 110 
Plasma of the blood. 17, 24 
Plasmodium malaria?, 125 

crescentic bodies, 131 
flagellate bodies, 132 
hyaline bodies, 127 
ovoid bodies, 131 
pigmented extracellular bodies. 
132 
intracellular bodies, 128 
segmenting bodies. 130 
spherical bodies, 131 
staining of, 126 
Plastic bronchitis, 293 
Plastodes, 232 
Plehn's stain, 126 
Pneumoconioses, 296 
Pneumonia, diplococcus of, 287 
in the blood, 118 
sputum in, 295 
Poikilocytes, 60 
Poikilocytosis, 60 
Polarimeter, 449 
Pole bacillus, 288 

Polychromatophilic degeneration, 63 
Polycythemia, 60 
Polrmastiarina, 235 
Polyuria. 302 
Propepsin. 174 
Prostatic fluid, 564 
Protagon, 280 

Proteids. formed in the stomach, 178 
of the blood, 47 
reactions of, 181 
Proteus vulgaris, 259 
Protozoa, 232 
in pus. 553 
in the blood, 113 
in the feces, 232 
in the sputum, 282 
in the urine, 542 
Pseudocysts, 525, 531 
Pseudogc-nococci, 541 
Pseudolymphocytes. 79 
Psorospermiasis, 239 
Ptomains in the feces, 262 

in the gastric contents, 195 
in the urine, 494 



Ptomains in the urine, isolation of, 496 
Ptvalin, 139 

test for, 139 
Pulmonary abscess, 294 

diseases, sputum in, 293 

gangrene, 294 

oedema, 296 

phthisis, 295 
Purin, 371 

bases, 371, 383 
Purulent exudates, 550 
Pus, 550 

chemistry of, 551 

crystals in, 553 

detritus in, 552 

general characteristics of, 550 

giant-corpuscles in, 552 

in the feces, 224 

in the gastric contents, 199 

in the urine, 519 

leucocytes in, 551 

microscopical examination of, 551 

parasites in, 553 

red corpuscles in, 552 

tests for, 519 
Putrescin, 262, 341, 495 
Putrid bronchitis, 293 

exudates, 550 
Pyogenie albumosuria, 409 
Pyrocatechin in the urine, 484 
Pyrocatechuic acid, 476 
Pyuria, 519 



Q 



UEYEXXE'S lactodensimeter, 578 



REACH'S test, 206 
Ked blood-corpuscles, 17, 58 

ana?mic degeneration of, 63 
behavior toward anilin dves, 

63 
degeneration of, 65 
enumeration of, 106 
granular, 65 
nucleated forms, 67 
variations in color, 62 
in form. 59 
in number, 60 
in size, 58 
Eelapsing fever, spirillum of, 123 
Eenal albuminuria, 401, 408 
Resorcin test, 165 

Resorptive power of the stomach, ex- 
amination of, 204 
Reynolds' test for acetone, 486 
Rhizopoda, 232 
Rice-water stools, 265 
Rosenbach's reaction, 464 

test for bile-pigments. 471 
Round worms, 239 
Roy's method of determining the specific 

gravity of the blood, 18 
Rust-colored expectoration, 271 



INDEX. 



595 



v< mil TRIMETER of Einhom, 117 
jj of Lohnstein, 1 18 

of Soleil-Ventzke, 450 
Saccharomyces oereviaise (see Yeasl ), 
Saliva, 138 

chemistry of, 138 
general characteristics of, 138 
in special diseases of the mouth, 143 
in the gastric contents, 198 
microscopical examination of, 140 
nitrites in. 139 

pathological alterations of, 142 
ptyalin in, 139 
test for nitrites. 139 
for ptyalin. L39 
for salphocyanides, 138 
Salivary corpuscles in, 1 K) 
Salivation. 142 

Salkowski's method of estimating oxalic 
acid in urine, 397 
zanthin-bases in urine. 384 
test for albumoses, 425 
for phenol. 483 
Salkowski-Neubauer method of estimat- 
ing the chlorides in urine, 325 
Snlkowski-Volhard method of estimating 

the chlorides in urine, 320 
Salol test of Ewald and Sievers, 204 
Sanarelli's Bacillus ietero'ides, 124 
Sarcina puiraonalis, 290 
urine, 542 



ventncnli, 



Ml 



Scherer's test for lencin, 510 
Schistosoma, 13 i 
Schizomycetes in the feces, 212 
Schlosing's method of estimating ammo- 
nia. 369 
Schmalz and "Peiper's method of deter- 
mining the specific gravity of the blood, 
19 
Scybala, 222 

itiona of the month, 1 
Sediments in acid urines, 500 
in alkaline urines, 513 
urinary, 299, 498 

ammonio-magnesium phosphate 

in, 504, 514 
ammonium urate in, 513 
amorphous urates in, 502 
basic magnesium phosphate in, 

505, 513 
bilirubin in, 512 
brick-dust, 501 
calcium carbonate in, 514 
oxalate in, 502 
sulphate in, 506 
cystin in, 507 
epithelial cells in, 515 
fat in, 512 

foreign bodies in, 543 
hsematoidin in, 512 
hippuric acid in, 506 
indigo in. 514 



Sediments, urinary, leucin in, 508 
leucocytes in, 518 

mode of examination of, 500 

monocalcium phosphate in, 505 
neutral calcium phosphate in, 

505 
non-organized, 600 

organized, 515 

red corpuscles in, 522 

soaps of lime ami magnesium in, 

512 
spermatozoa in, 535 
tube easts in, 525 
tumor-particles in, 5 13 
ty rosin in, 508 
urates in, 502, 513 
uric acid in, 500 
xanthin in, 511 
Seegen-Schn eider method of estimating 

nitrogen, 300 
Semen. 50-1 

chemistry of, 564 
general characteristics of, 504 
microscopical examination of, 565 
pathology of, 500 
recognition of, in stains. 566 
spermatic crystals in, 504 
spermatozoa in, 505 
Sepsis, organisms in the blood in, 120 
Seropurulent exudates, 548 
Serous exudates, 5 18 
Serum albumin in the blood, 26 
in the urine, 398 

estimation of, 422 
tests for, 415, 421 
Serum-globulin in the blood, 26 
in the urine. 409 

estimation of, 424 
test for, 424 
Shiga's bacillus, 259 
Siderosis, 297 
Skatol in the feces. 216 
tests for, 216 
xv I. 481 
sulphate. 481 
Smegma bacillus, 288, 539 
Soaps of lime and magnesium in the 

urine, 51 2 
Sodium chloride in hydatid fluid, : ' : >7 
Spectroscope, 16 
spermatic crystals, 291 
Spermatocystiti>. 536 
Spermatorrhoea, 536 
Spermatozoa in the semen, 565 

in the urine. 535 
Spermin, 565 
Spiegl i - '- reagent, 421 
Spirals of < Surschniann, 275 
Spirillum of relapsing fever. 123 
Spirochreta < tbermeieri, 123 
Sporozoa, 239 
Sputum, 269 

Amoeba coli in, 283 



596 



INDEX. 



Sputum, amount of, 270 
bacteria in, 288 
blood in, 271, 278 
cheesy particles in. 273 
chemistry of. 2! _ 
color of, 271 
concretions in, -~~ 
configuration of. 272 
consistence of. 270 
crudum. _"_ 
crystals' in. 27C 1 . 
Curschmann's spirals in. 275 
Distoma pulmonale in, 283 
echinococcus in. 276. 2^1 
elastic tissue in, 273, 280 
epithelial cells in, 278 
fibrinous casts in, 273 
foreign bodies in. 277 
general characteristics of, 27 
i,". : . .-\;.~. -~- 
he crogeneous, 272 
homogeneous. 272 
in various diseases, 293 
leucocytes in. 277 
macroscopical constituents. 27* 
microscopical examination of, 27 
nummular. U72 
odor of, 271 
parasites, animal, in. 281 

vegetable, in. 285 
specific gravity of, 272 



Sugar in the urine, 430 
tests for, 438 

Sulphanilic acid test see Ehrlich's reac- 
tion). 
Sulphates in the urine. 334 
conjugate. 336. 481 
r-:imation of, 338 
mineral. 
tests for, 337 
Sulphocyanides in the saliva. 138 

in the nrine. 340 
Sulphur, neutral, in urine. 340 
estimation of. 342 

HPJEXlA cucumerina. 243 
j A diminuta. 243 

echinococcus. 2 SI 

flavapunctata. 243 

mediocanellata. 240 

nana. 242 

saginata. 240 

solium, 241 
Tartar, 144' 

-carbaminic acid in urine. 341 
Teichmami's crystals, 43 
I est-hreakfast of Boas, 150 

of Ewald and Boas, 149 
Te-:-dinner of Eiegel, 149 
Test-meal of Saizer. 150 
T :-:-:: - . - " - 
Thecosoma. 136 



technique in the examination of, 269 Thiosulphates in urine. 342 



Squibb's ureometer. 302 
Staphylococcus pyogenes albus, 120 
aureus. 12 
citreus. 120 
Starch, digestion of, 139 

solution. 189 
Steatorrhcea. 225 
Stercobilin, 220, 472 

Stercoraceous material in the vomit. 199 
Si kes? fluid, 30 
Bl orach, motor power of, 203 

rate of absorption in. 204 

washing, 153 
Stomach-tube. 150 

contraindications to its use, 151 

its introduction. 151 
Stomatitis, catarrhal. 143 

gonorrhoeal. 1 

ulcerative. 143 
Stools (see Feces). 
Strauss' test for lactic acid, 186 
Streptococcus pyogenes. 120 
brevis. 1 2 
conglomeratus, 121 
loneus. 1 2 
Strongyloides, 232 
Strongylus dnodenalis, - 
Stye - - 1 _ 

Succinic acid in hydatid fluid, 557 
Sudan stain f<»r fat, 513 
Sugar in the blood. 28, 49 



105 



.a- Zeiss' hamiocvtorueter. 
Thrush. 144 
T is n's fluid. 106 
Toilens' orcin test. 453 

phloroglucin test. 453 
T >ngoe, coating of, 144 
Tonsillitis, 145 
Tonsils, coating of, 145 
Topfer's method of estinjating hydro- 
chloric acid. 168 

test for hydrochloric acid. 164 
T "albumins in the gastric contents. 195 
Transitory srlucosuria. 4 4 
Transudate-. &4S 

albumin in, " 4 

chemistry of. 547 

coagulation of. 

general characteristics of ' - ' 

microscopical examination of, 548 

specific gravity of. 545 
Trematodes, 245 

ina cystica. 135 

sanguinis hominis uocturna, 135 

spiralis, 251 
Trichocepbalus dispar, 25 
Trichomonads in the : 

in the sputum. 282 

in the stomach contents. _ 

in the urine. 542 

in vaginal discharges 
Trichomonas vaginalis, 236, 2^2. 542 



INDEX. 



597 



Trichotrachelides, 250 
Triple phosphate crystals in the sputum, 
292 ' 
in the urine, 504, 514 
Tripperfaden, 52] 
Trommel's tost, 439 

Tropseolin test for hydrochloric acid, 166 
Trypsin, -~> s 7 

in pancreatic cysts, 557 
test for, 557 
Tube-casts in the urine, 525 
amyloid, 530 
blood, 527 

clinical significance of, 532 
compound hyaline, 527 
epithelial, 527 
fatty, 529 
formation of, 531 
granular, 527 
hyaline, 526 

mode of examination of, 526 
psendo, 525 
pus, 527 
staining of, 526 
true, 525, 526 
waxy, 529 
Tubercle bacillus, 2S3 

detection of, 283 
in pus, 553 
in the blood, 121 
in the cerebrospinal fluid, 562 
in the feces, 256 
iu the milk, 578 
in the mouth, 143 
in the sputum, 283 
in the urine, 539 
Tuberculosis, bacillus of, 283 
Tumor-particles in the gastric contents, 
203 
in the urine, 543 
Typhoid fever, bacillus of, 111, 251 
in the blood, 114 
in the feces, 254 
stools in, 265 
Tyrosin, 508 

in the sputum. 292 
in the urine, 508 
test for, 509 

UFFELMANlFSl Bt for lactic acid, 185 
Unorganized sediments in urin< 
Uraemia, 53 
Urates in urinary sediments, 502, 513 

Urea in the blood. 52 
in the urine, 343 

estimation of, 355 

isolation of, 35 \ 

origin of, 3 18 

properties of, 361 

tests for, 351 
nitrate, 352 
oxalate, 353 
Ureometers, 355 



Ureometers, Doremus*, 357 

I hreen's, 361 

I I ii filer's, 361 

Marshall's, 361 

Simon's, 356 
Squibb's, 362 
Urethritis, gonorrhoea!, 540 
Uric acid, 370 

crystals of, 500 
diathesis, 37 I 
estimation of, 54, 377 
Folin's method, 378 
gravimetric method, 379 
rJaycraft's method, 379 
Hopkins' method, 377 
Ludwig - Salkowski's me- 
thod, 381 
in sediments, 500 
in the blood, 53 
in the urine, 370 
properties of, 375 
tests for, 377 
Urinary cylinders, 525 

sediments, 500 
Urine, 298 

acetone in, 484 
acidity of, 314 
albumins in, 398 
albumoses in, 409 
alkapton in, 475 
alloxur bases in, 383 
ammonia in, 368 
animal gum in, 45 1 

parasites in, 542 
Bence Jones' albumin in, 411 
benzoic acid in, 386 
bile acids in, 471 

pigments in, 468 
blood in, 412, 466, 522 
carbohydrates in, 430 
casts in, 525 
chemistry of, 315 
chlorides in, 317 
cholesterin in, 471 
chroraogens in, 155 
chyle in, 136, 414, 492, 513 
color of, 299 
consistence of, 301 
cystin in, 507 

dextrin in. 452 

diacetic acid in, 189 
Ehrlich's reaction in, 479 
epithelium in. 515 
fat in, 492, 512 
fatty acids in, 491 

\'n<-,\\ matter in. 5 13 

ferments in, 493 
fibrin in, 1 1 I 
foreign bodies in, 5 !■'> 
gases in, 193 

al appearance of, 299 
chemical composition of, 315 
glucose in, 130 



598 



INDEX. 



Urine, glucuronic acid in, 454 

haemoglobin in, 412 

hippuric acid in, 385 

hist on in, 415 

indican in, 458 

inosit in, 455 

kreatin in, 388 

kreatinin in, 388 

lactic acid in, 490 

lactose in, 452 

laiose in, 453 

leucocytes in, 518 

levulose in, 452 

maltose in, 452 

melanin in, 474 

microscopical examination of, 49S 

mineral ash, estimation of, 316 

neutral sulphur in, 340 

nitrogen in, 343, 364 

nubecula in, 299 

nucleo albumin in, 414 

nucleohiston in, 415 

odor of, 301 

organized sediments in, 515 

oxalic acid in, 392, 502 

oxaluric acid in, 392 

oxybutyric acid in, 

parasites in, 536 

pentoses in, 453 

phenol in, 475, 483 

phosphates in, 325, 505 

pigments in, 455 

ptomains in, 494 

pus in, 518 

pyrocatechin in, 475, 484 

quantity of, 301 

reaction of, 310 

sediments in, 498 

serum -albumin in, 398 

serum-globulin in, 409 

skatoxvl sulphate in, 481 

solids in, 310 

specific gravity of, 305 

spermatozoa in, 535 

sugar in, 430 

sulphates in, 334 

sulpbur, neutral, in. 340 

tumor-particles in, 542 

urea in, 343 

uric acid in, 370, 500 

urobilin in, 455, 471 

urochrome in, 455 

uroerythrin in, 457 

urobaematin in, 464 

urohaematoporpbyrin in, 466 

urorosein in, 465 

vegetable parasites in, 536 

xanthin-bases in, 383 
Urines, blue, 478 

green, 478 
Urinometer, 308 
Urobilin, febrile, 455, 473 

identitv with stercobilin, 220 



Urobilin, normal, 455, 471 
pathological, 471 
tests for, 473 
Bang's, 426 
Gerhardt's, 473 
Urobilinogen, 471 
Urobilhmria, 471 
I Urochrome, 455 
j Uroerythrin, 457 
Urofuscohaematin, 466 
Uroha?matin, 464 
Urohaernatoporphyrin, 466 
Uroleucinic acid, 476 
Urophain, Hellers, 465 
Urorosein, 465 
Urorosein ogen, 465 
Urorubrohaeinatin, 466 
Uroxanthinic acid. 476 
Urrhodinic acid, 476 

T7AGINAL blennorrhea, 571 

) discharges, 569 

bacteria in, 569 

during menstruation, 571 

following parturition. -571 

general description of, 569 

in abortion. 572 

in gonorrhoea, 572 

in membranous dvsmenorrhoea, 
572 

in uterine cancer, 572 

in vaginitis. 572 

in vulvitis, 572 

parasites in, 569, 570 

reaction of, 569 
Vaginitis exfoliativa. 572 
Valeur globulaire, 34 
Vermes in the blood, 135 
in the feces. 239 
in the sputum, 281 
in the urine, 543 
Vitalli's test for pus, 519 
Vomited material, 196 

bile in, 198 

blood in, 198 

food material in, 196 

mucus in. 197 

odor of, 200 

pancreatic juice in, 198 

parasites in. 200 

pus in, 199 

saliva in, 198 

stercoraceous material in, 199 
Vomitus matutinus, 159, 198 
v. Fleischrs haemometer, 32 

WANG'S estimation of indican, 462 
WassilieWs estimation of albumin, 
422 
Waxy casts, 529 
Weiirert-Ebrlich stain, 2S6 
Weigert's elastic tissue stain, 281 
Weyl's test for kreatinin, 390 



INDEX. 



599 



Whetstone crystal- Bee Uric acid), 500 
White blood- corpuscles see Leucocytes), 

i in 
Whooping-cough, bacillus o\\ 288 

sputum in. 288 

Widal's serum-test, 114 
Williamson's blood-test in diabetes, 50 
Will-Varrentrapp's method of estimating 
uitrogen, 300 

"Woodward's method of estimating milk- 

proteids, 580 
"Worms (see Vermes), 239 



XANTHIN-KASKS in the blood, 55 
in the urine, 371, 383, 51 1 
estimation of, -"> v I 
Xanthoproteic reaction, 217 

YEAST-CELL8 in the gastric con- 
tents, 201 

in the urine, 5 12 
Yellow fever, bacillus of, 12 1 

ZIEHL-NEELSEN stain, 287 
Zymogens in the gastric juice, 173 






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looa 



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1 COPY DEL. TO CAT. DIV. 
17-1902 



m 



■*m 



